VERY IMPORTANT TOPIC AS PER PRACTICAL AND ACEDEMIC POINT OF VIEW. ALL THE ASPECTS OF THE TOPIC ARE COVERED IN THESE SLIDES... ENJOY

1. MALUNITED DISTAL END
RADIUS FRACTURES : THEIR
MANAGEMENT
PRESENTED BY:-
DR NITISH KHOSLA
PG RESIDENT ORTHOPEDICS
DMCH LUDHIANA

2. TOPICS
1. INTRODUCTION
2. IMPORTANT MEASUREMENTS
3. CLINICAL EVALUATION
4. RADIOGRAPHIC EVALUATION
5. OPERATIVE TREATMENT– A. CORRECTING DEFORMITY
B. TREATING PATHOLOGIC PROCESS
OF DRUJ
C. SALVAGE PROCEDURES

3. INTRODUCTION
• THE DESIRE FOR ANATOMIC RESTORATION OF THE DISTAL RADIAL
JOINT OFTEN IS THE RATIONALE FOR OPERATIVE TREATMENT.
• AS LITTLE AS 1 MM OF INCONGRUITY OF THE ARTICULAR SURFACE WITH
WORSE OUTCOMES
• MALUNION REMAINS A COMMON CAUSE OF RESIDUAL DISABILITY AFTER
DISTAL RADIUS FRACTURES.
• 2ND MC COMPLICATION (5-17%) AFTER WRIST JOINT ARTHRITIS/ARTHROSIS
(7 – 65%)

4. • MALUNION IS CAUSED BY FAILURE TO ACHIEVE AND MAINTAIN AN
ACCURATE REDUCTION OR BY INADEQUATE DURATION OR TYPE OF
IMMOBILIZATION
• INADEQUATE REDUCTION BECAUSE OF –
1. MARKED COMMINUTION
2. SEVERE OSTEOPOROSIS
3. DISRUPTION OF DRUJ LIGAMENTS
4. AGE > 60YRS
• ASSOCIATED WITH– A . E/A DEFORMITIES- SHORTENING AND
EXCESSIVE DOSRAL OR VOLAR TILT
B. I/A MALALIGNMENT
C. DRUJ INCONGRUITY OR INSTABILTY

5. IMPORTANT MEASUREMENTS
DISTAL RADIO-ULNAR JOINT CONGRUITY CAN BE SEEN BY THE
FOLLOWING MEASUREMENTS-
• PALMAR TILT – NORMAL RANGE IS 11 TO 12 DEGREES
• RADIAL INCLINATION – NORMAL RANGE IS 20 TO 23
DEGREES
• ULNAR VARIANCE – NORMAL RANGE IS 0 TO -2MM
• RADIAL LENGTH – NORMAL RANGE IS 10 TO 12 MM
• CARPAL MAL-ALIGNMENT

6. 1) VOLAR / PALMAR TILT
• ON A TRUE LATERAL VIEW A LINE IS DRAWN CONNECTING THE
MOST DISTAL POINTS OF THE VOLAR AND DORSAL LIPS OF THE
RADIUS. THE VOLAR OR PALMAR TILT IS THE ANGLE CREATED
WITH A LINE DRAWN PERPENDICULAR TO THE LONGITUDINAL
AXIS OF THE RADIUS.

7. 2) RADIAL LENGTH / HEIGHT
• RADIAL LENGTH IS MEASURED ON THE AP RADIOGRAPH AS THE DISTANCE
BETWEEN ONE LINE PERPENDICULAR TO THE LONG AXIS OF THE RADIUS
PASSING THROUGH THE DISTAL TIP OF THE RADIAL STYLOID & SECOND LINE
INTERSECTS DISTAL ARTICULAR SURFACE OF ULNAR HEAD.

8. • THIS IS A MEASURE OF RADIAL SHORTENING AND SHOULD NOT BE
CONFUSED WITH
MEASUREMENT OF RADIAL LENGTH. ULNAR VARIANCE IS THE VERTICAL
DISTANCE
BETWEEN A LINE PARALLEL TO THE MEDIAL CORNER OF THE ARTICULAR
SURFACE OF THE
RADIUS AND A LINE PARALLEL TO THE MOST DISTAL POINT OF THE
ARTICULAR SURFACE OF
THE ULNAR HEAD, BOTH OF WHICH ARE PERPENDICULAR TO THE LONG AXIS
OF THE RADIUS

9. 4)RADIAL INCLINATION
ON THE AP VIEW THE RADIUS INCLINES TOWARDS THE ULNA. THIS IS
MEASURED BY THE
ANGLE BETWEEN A LINE DRAWN FROM THE TIP OF THE RADIAL STYLOID TO
THE MEDIAL
CORNER OF THE ARTICULAR SURFACE OF THE RADIUS AND A LINE DRAWN
PERPENDICULAR TO THE LONG AXIS OF THE RADIUS.

10. 5)CARPAL MALALIGNMENT
ON A LATERAL VIEW ONE LINE IS DRAWN ALONG THE LONG AXIS OF THE
CAPITATE AND ONE DOWN THE LONG AXIS OF THE RADIUS. IF THE CARPUS IS
ALIGNED, THE LINES WILL INTERSECT WITHIN THE CARPUS. IF NOT, THEY WILL
INTERSECT OUT WITH THE CARPUS

11. CLINICAL EVALUATION
• TYPICAL SYMPTOMS OF MALUNION:-
1. PAIN – DRUJ/CARPAL AREA/ RADIOCARPAL AREA
2. WEAKNESS OF GRIP
3. REDUCED ROM ESP ROTATION
4. DEFORMITY

12. PAIN
• DRUJ – INCONGRUENCY OF SIGMOID NOTCH
• RADIOCARPAL- I/A MALALIGNMENT OR OA IN R-C JOINT
• CARPAL PAIN – ALTERED MECHANICS OF THE MALALIGNED
CARPUS

13. WEAKNESS OF GRIP
• COMBINATION OF PAIN AND ALTERED WRIST MECHANICS
• DORSALLY TILTED MALUNION- INC PRESSURE WITHIN CARPEL
TUNNEL MEDIAN NERVE COMPRESSION
• RUPTURE OF EXTENSOR TENDONS (MC EPL)

14. REDUCED RANGE OF MOTION
• MOST FREQUENTLY – FOREARM ROTATION
• DEC WRIST FLEXION- DORSALLY TILTED MALUNION (N- 60-
80˚)
• DEC WRIST EXTENSION- VOLAR TILTED MALUNION (N- 60-70˚)
• IMPAIRED ULNAR DEVIATION- LOSS OF RADIAL INCLINATION
(N- 30-40˚)
• DEC PRONATION AND SUPINATION- MALUNITED SMITH
FRACTURES
(N- 70- 80˚) (N- 80-85˚)

15. DEFORMITY
DINNER FORK
DEFORMITY
(COLLES
FRACTURE)
GARDEN SPADE
DEFORMITY
(SMITH FRACTURE)

16. RADIOGRAPHIC EVALUATION
• PLAIN AP AND LATERAL RADIOGRAPHS IN NEUTRAL POSITION
• CT TO EVALUATE CONGRUITY OF DRUJ AND CONDITION OF
THEARTICULAR SURFACE
• MRI OR ARTHROGRAPHY USED TO EVALUATE THE INTEGRITY OF
TRIANGULAR FIBROCARTILAGE COMPLEX AND INTERCARPEL
LIGAMENTS.

17. GRAHAM’S RADIOGRAPHIC CRITERIA

18. OPERATIVE TREATMENT
• SELDOM INDICATED FOR MINIMALLY SYMPTOMATIC PATIENTS
DESPITE RADIOGRAPHIC OR COSMETIC DEFORMITY.
• C/I IN ACTIVE REFLEX SYMPATHETIC DYSTROPHY SYNDROME
(COMPLEX REGIONAL PAIN SYNDROME; CRPS)

19. CRPS- DISTRESSING COMPLICATION AFTER
FRACTURE AROUND WRIST JOINT (THE SURGERY
NEEDS TO BE DELAYED)
• EARLY STAGE- EXTREME SWELLING OF SOFT TISSUE, TENDERNESS TO
PRESSURE AND PAIN ON MOTION
• LATER STAGE- CIRCULATORY CHANGES IN SOFT TISSUE AND BONE;
SKIN BECOMES PURPLISH AND COLD
• EVEN LATER STAGE – STIFFNESS OF FINGER AND WRIST JOINT EVEN
SHOULDER AND ELBOW (IMMBOLIZATION OF EXTREMITY IN ONE
POSITION)
• RADIOGRAPH- MOTTLED DECALCIFICATION OR OSTEOPOROSIS

21. TREATMENT:
MINIMAL IMMOBILIZATION WITH ACTIVE AND
PASSIVE EXERCISES
SYMPATHETIC BLOCKS
OCCUPATIONAL AND PHYSICAL THERAPY

22. OPERATIVE OPTIONS
A. CORRECTING DEFORMITY OF DISTAL RADIUS
B. TREATING PATHOLOGIC PROCESS OF DRUJ
C. SALVAGE PROCEDURES

23. A. CORRECTING DEFORMITY OF DISTAL
RADIUS
DORSALY TILTED MALUNIONS (MALUNITED
COLLES)
• OSTEOTOMY AND INTERNAL FIXATION
• INTRAMEDULLARY NAILING
• EXTERNAL FIXATION

25. OSTEOTOMY AND INTERNAL FIXATION
• DORSAL LONGITUDINAL APPROACH USED
1. STRAIGHT DISTAL RADIAL INCISION PARALLEL TO THE
LONG AXIS OF THE RADIUS, BEGINNING 2 CM DISTAL
TO THE LISTER TUBERCLE AND EXTENDING 8 CM
PROXIMALLY INTO THE FOREARM.

26. 2. INSERT A KIRSCHNER WIRE 4
CM PROXIMAL TO THE
OSTEOTOMY
SITE AND PERPENDICULAR TO
THE LONG AXIS OF THE RADIUS.
■ INSERT A SECOND KIRSCHNER
WIRE INTO THE DISTAL PORTION
OF
THE RADIUS PERPENDICULAR TO
THE JOINT.

27. 3. OSTEOTOMY IS
MADE AND OPENED
DORSALLY UNTIL
THE TWO WIRES ARE
PARALLEL TO
RESTRORE THE
NORMAL VOLAR
TILT OF 5 TO 10
DEGREES TO THE
DISTAL ARTICULAR
SURFACE

28. 4. THE
PALMER
CORTEX IS
LEFT
INTACT
AND THE
FRAGMEN
T IS
LEVERED
INTO
POSITION

29. 5. BONE GRAFT
IS INSERTED
AND TAMPED
IT INTO PLACE
AFTER
CORRECTING
ROTATION
DEFORMITY OF
THE DISTAL
FRAGMENT

30. 6. A SMALL T-
PLATE IS
CONTOURED
TO FIT THE
RADIUS
PERFECTLY
AND
STABILIZED IT
WITH
TWO/THREE
SCREWS IN
EACH
FRAGMENT.

31. INTRA MEDULLARY NAILING

32. • REQUIRES REDUCTION OF DISTAL RADIUS
BEFORE INSERTION OF IM NAIL
• INDICATIONS:
1- DISTAL RADIAL DEFORMITY OF > 15
DEGREE RADIAL INCINATION
2 4MM LOSS OF RADIAL LENGTH
3 4MM ULNAR VARIANCE
4 15 DEGREE DORSAL OR 20 DEGREE
VOLAR LATERAL TILT

33. EXTERNAL FIXATION :-
MINIMALLY INVASIVE TECHNIQUE
EASY CONTROL AND CORRECTION OF THE DISTAL
FRAGMENT
THE USE OF NONSTRUCTURALCANCELLOUS BONE
GRAFT
EASE OF REMOVAL OF THE IMPLANT

34. VOLAR TILTED MALUNION (MALUNITED
SMITH)

35. • LESS COMMON THAN DORSALLY TILTED
MALUNION
• DEC GRIP STRENGTH, DEC WRIST EXTENSION
• LIMITED SUPINATION
• COSMETIC DEFORMITY
• INCONGRUENCE AND INSTABILITY OF DRUJ
• VOLAR OPENING OSTEOTOMY OF DISTAL
RADIUS WITH BONE GRAFTING AND
PLATING FOR SYMPTOMATIC MALUNITED
SMITH FRACTURES

36. VOLAR OSTEOTOMY
1. PLAN
THE
OSTEOTOM
Y SO THAT
IT IS
TRANSVERS
E IN THE
FRONTAL
PLANE AND
OBLIQUE IN
THE
SAGITTAL

37. 2. K WIRE
DRILLED INTO
THE RADIAL
SHAFT PROXIMAL
TO THE SITE OF
OSTEOTOMY
AND
PERPENDICULAR
TO THE LONG
AXIS OF RADIUS
ANOTHER K WIRE
DRILLED INTO
THE DISTAL
FRAGMENT
PERPENDICULAR

38. 3. OSTEOTOMY
MADE AND SMALL
EXTERNAL
FIXATOR FRAME
USED TO
MAINTAIN
CORRECTED
ALIGNMENT
BEFORE
PLACEMENT OF
BONE GRAFT,
PLATE AND

39. 4. WEGDE
OPEN THE
OSTEOTOMY
WITH A SMALL
LAMINA
SPREADER
CLAMP,
PRESERVING
THE DORSAL
PERIOSTEUM

40. 5. INSERT THE
GRAFT AND
STABILIZE THE
OSTEOTOMY
WITH A 3.5MM
ANGLED T –
SHAPED PLATE

41. POST OP :-
• VOLAR SPLINT FOR 2 WEEKS
• IF LENGTHENING OF > 10MM IS NECESSARY  B/E
CAST FOR 6 WEEKS
• EXERCISES AND ACTIVITES OF DAILY LIVING TO BE
ENCOURAGED AFTER REMOVING THE CAST
• ACTIVITIES AGAINST RESISTENCE TO BE AVOIDED
UNTILL 8 WEEKS/ UNTILL RADIOGRAPHIC UNION
CONFIRMED

42. B. TREATING PATHOLOGIC PROCESS OF
DRUJ
•BOWER PROCEDURE
•SAUVE- KAPANDJI
PROCEDURE
•DARRACH’S PROCEDURE
•ULNAR SHORTENING
ULNAR SIDED PROCEDURES
INDICATED FOR :-
PERSISTENT PAIN
ROTATIONAL CONTRACTURE
INSTABILITY OF DRUJ
 MAY BE PERFORMED IN
CONJUNCTION WITH DRO

43. BOWER’S PROCEDURE / HEMI RESECTION
ARTHROPLASTY
PARTIAL RESECTION OF THE
ARTICULAR SURFACE OF ULNA
INTERPOSING A CAPSULAR
FLAP
ULNOCARPAL IMPACTION IS A
RELATIVE CONTRAINDICATION
PREFERRED FOR DRUJ
ARTHROSIS WITH MILD DEGREE
OF POSITIVE ULNAR VARIANCE

44. SAUVE- KAPANDJI PROCEDURE
• DRUJ FUSION WITH
PROXIMAL ULNAR
PSEUDOARTHROSIS.
• SEGMENTAL EXCISION OF
ULNA AT THE LEVEL OF
ULNAR NECK UPTO 10-
15 MM
• ULNAR HEAD IS
RETAINED AND FUSED
VIA SCREWS TO THE
SIGMOID NOTCH

45. DARRACH’S PROCEDURE
• COMPLETE ABLATION OF DISTAL ULNA
• REMOVES THE DISTAL ARTICULAR SURFACE OF
ULNA
• USEFUL IN ELDERLY AND IN PATIENT WITH
LIMITED ACTIVITY
• FCU OR ECU TENDON SLINGS ARE ATTACHED
TO THE DISTAL ULNA TO ADDRESS THE ULNAR
INSTABILITY

46. ULNAR SHORTENING
• INDICATED IN SYMPTOMATIC
ULNOCARPAL IMPINGEMENT
• ISOLATED US IN CASE RADIUS
HAS SHORTENED WITH NO
ANGULAR DEFORMITY
• TRANSVERSE OSTEOTOMY
FOLLOWED BY COMPRESSION
PLATING.

48. C. SALVAGE PROCEDURES
• SYMPTOMATIC COMMINUTED I/A FRACTURES AND DISTAL RADIAL MALUNIONS THAT
DEVELOP POST TRAUMATIC ARTHRITIS
1. TOTAL WRIST ARTHRODESIS
TREATMENT OF CHOICE IN YOUNG PATIENTS
STABLE PAINLESS WRIST ACHIEVED; THOUGH MOTION IS SACRIFICED
DISTAL ULNA USUALLY RESECTED ALONG WITH ARTHRODESIS
2. PARTIAL WRIST ARTHRODESIS
ARTHRITIS LIMITED TO RADIOCARPEL JOINT ONLY
3. RADIOSCAPHOLUNATE ARTHRODESIS
IF ENTIRE RADIOCARPEL JOINT IS INVOLVED
4. RADIOLUNATE ARTHRODESIS
DIE- PUNCH INJURY OF LUNATE FACET A/W ARTHRITIS

49. •PROXIMAL ROW CARPECTOMY :--
MOTION PRESERVING PROCEDURE
IN CASES WHERE DEGENERATIVE ARTHITIS IS LIMITED
ONLY TO RADIAL SIDE OF THE WRIST, PRC IS AN OPTION.