MALUNITED DISTAL RADIUS FRACTURE FEATURES AND MANAGMENT

1. MALUNITED DISTAL RADIUS
FRACTURE
BY DR NISCHAY KAUSHIK
JR2 ORTHOPAEDICS
IGIMS,PATNA

2. ANATOMY
• The distal radius is biconcave , triangular &covered with
Hyaline cartilage.
• The articular surface has two facets for articulation with the
scaphoid & the lunate.
• The medial surface forms a semi-circular notch which
articulates with the ulnar head.
• The triangular fibrocartilage(TFC) is a KEY stabilizer of
distal radioulnar joint.

4. COMMON CLASSIFICATION
• GARTLAND AND WERLEY.
• FRYKMAN (radiocarpal and radioulnar)
• AO CLASSIFICATION
• MELONE CLASSIFICATION(impaction of lunate)
• FERNANDEZ(mechanism)

6. FRYKMAN CLASSIFICATION

9. Fernandez classification

10. COLLE’S FRACTURE
It is an EXTRAARTICULAR fracture that occurs at CORTICOCANCELLOUS
JUNCTION of distal end of radius within 2cm from the articular surface
It may extend into DRUJ with six displacements,
• Impaction
• Lateral displacement
• Lateral rotation (angulation)
• Dorsal displacement
• Dorsal rotation (angulation)
• Supination.
It may often accompany fracture of the ulnar styloid which signify avulsion of the
TFCC and ulnar collateral ligaments

11. Colle’s fracture

12. SMITH’S FRACTURE
(REVERSE COLLE’S FRACTURE)
• Occurs at the same level on the distal radius as a colle’s
fracture . Distal fragment displaced in Palmar (volar)
direction with a “Garden spade" deformity.
• Modified Thomas Classification of Smith's Fracture:
Type I: Extra-articular
Type II: Crosses into the dorsal articular surface
Type III: Enters the radio-carpal joint(equivalent to volar
barton fracture dislocation)

13. MECHANISM OF INJURY

14. BARTON’S FRACTURE
It is an INTRARTICULAR fracture dislocation
or subluxation in which the rim of the
distal radius is displaced dorsally or volarly
with the hand and carpus.
Extends from the articular surface of the
radius to either its anterior/posterior
cortices

15. BARTON’S FRACTURE
There are 2 types:
1. Dorsal barton
2. Volar barton
1.Dorsal Barton:
Dorsal rim fracture of distal radius
Mechanism:
Fall with dorsiflexion and pronation of the distal forearm on a flexed wrist.
2.Volar Barton:
Palmar rim fracture of distal radius
Mechanism:
It is due to palmar tensile stress and dorsal shear stress and is usually combined with radial styloid fracture.

16. CHAUFFEUR’S FRACTURE
• It is an Intraarticular fracture involving the radial styloid,the radius is
cleaved in a sagittal plane and the fragment is displaced proximally.
• Isolated fracture of the radial styloid are fairly common from backfiring of
starting handle of car.

18. Complications
• Mal-union ( may needs augmentation with additional casting)
• Pin track infection
• Finger stiffness
• Loss of reduction more common than plating
• Tendon rupture
• nerve injury

19. RADIOGRAPHIC PARAMETERS
View Measurement Normal Acceptable criteria
AP Radial height 13 mm <5 mm shortening
Radial inclination 23 degrees change <5°
Articular step off congruous <2 mm step off
LAT Volar tilt 11 degrees
dorsal angulation <5°
or within 20° of
contralateral distal
radius

20. Radial inclination = 23°
Radial length = 12mm
Volar tilt = 10°
Scapholunate angle = 60° +/- 15°
NORMAL PARAMETER

21. MALUNION
• A malunion occurs when a fractured bone heals with improper
alignment, incorrect length ,articular incongruity or combination of
these factors
• Malunion of distal radius may be intra articular or extra articular,
symptomatic or asymptomatic.

22. BASIC CRETERIA TO DEFINE MALUNION
• RADIAL INCLINATION <10 DEGREE
• VOLAR TILT>20 DEGREE, DORSAL TILT>15 DEGREE
• RADIAL HEIGHT<10 mm
• ULNAR VARIANCE>2+
• INTRA ARTICULAR STEP OR GAP >2 mm

23. Clinical features
• Decrease in 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

24. Clinical features
• Excessive dorsal 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.

25. Predictors of poor outcomes fernandez et al
• Distal radius articular step of >2 mm
• DRUJ step of 1-2mm
• Doral tilt more than 15-20 degree
• Volar tilt of more than 20 degree
• Radial length of less than 6 mm
• Radial inclination of less than 10
degree

26. 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

27. Operative treatment
• Not all 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

28. GRAHAMS CRITERIA FOR RADIOLOGICAL
ACCEPTABLE DISTAL RADIUS MALUNION
• Radial length---- shortening of < 5mm
• Radial inclination- >15 degree
• Radial tilt – dorsal < 15 degree
Volar < 20 degree
• Articular incongruency – step of < 2mm at radiocarpal joint

29. INDICATIONS
• All symptomatic malunions.
• Decreased grip strength and mobility.
• 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.
• Carpal tunnel syndrome

30. Contraindications
• active complex regional pain
syndrome
• osteopenia
• advanced radiocarpal arthrits
• poor soft tissue coverage
• acceptable function despite deformity

31. STRATEGIES OF TREATMENT
• 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

32. 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

33. Fernandez osteotomy
• Dorsal 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)

34. Fernandez osteotomy

35. Shea osteotomy
• Volar henry 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)

36. Shea osteotomy

37. INTRA MEDULLARY NAILING

38. INDICATION FOR IM NAILING
• Distal radial deformity of >15 degree.
• 4 mm loss of radial length.
• 4 mm Ulnar variance.
• 15 degree dorsal or 20 degree volar lateral tilt.

39. EXTERNAL FIXATOR
• MINIMALLY INVASIVE TECHNIQUE
• EASYCONTROL AND CORRECTIONOFTHE DISTAL FRAGMENT
• THE USEOFNONSTRUCTURALCANCELLOUS BONE GRAFT
• EASEOFREMOVAL OFTHE IMPLANT

40. OSTEOTOMY MADE AND SMALL
EXTERNAL FIXATOR FRAME USED
TO MAINTAIN CORRECTED
ALIGNMENT BEFORE PLACEMENT
OF BONEGRAFT, PLATE AND

41. OPEN WEDGEOSTEOTOMY
WITH A SMALL LAMINA
SPREADER CLAMP,
PRESERVING THE DORSAL
PERIOSTEUM

42. Proceedures to correct DRUJ 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.

43. Proceedures to correct DRUJ incongruency
• DRUJ preservation surgeries;
Ulnar shortening osteotomy
• DRUJ ablation sugeries;
1. Darrach’s procedure
2. Bowers arthroplasty-
partial resection of
distal ulna
3. Sauve- kapandji Proceedure - druj
fusion + prox ulnar
pseudoarthosis

44. ULNAR SHORTENING
•INDICATED IN SYMPTOMATIC
ULNOCARPAL IMPINGEMENT
•ISOLATED USEIN CASERADIUS
HAS SHORTENED WITH NO
ANGULAR DEFORMITY
•TRANSVERSEOSTEOTOMY
FOLLOWED BYCOMPRESSION
PLATING.

45. DARRACH’S PROCEDURE
•COMPLETEABLATION OFDISTAL ULNA
•REMOVESTHE DISTAL ARTICULAR SURFACEOF ULNA
•USEFULIN ELDERLYAND IN PATIENT WITH LIMITED
ACTIVITY
•FCUORECUTENDON SLINGSAREATTACHED TO THE
DISTAL ULNA TO ADDRESSTHE ULNAR INSTABILITY

46. BOWER’SPROCEDURE/ HEMI RESECTION
ARTHROPLASTY
PARTIAL RESECTIONOFTHE
ARTICULAR SURFACEOFULNA
INTERPOSINGA CAPSULAR FLAP
ULNOCARPAL IMPACTION IS A
RELATIVE CONTRAINDICATION
PREFERREDFORDRUJ ARTHROSISWITH
MILD DEGREE OFPOSITIVE ULNAR
VARIANCE

47. SAUVE- KAPANDJI PROCEDURE
•DRUJFUSIONWITH
PROXIMAL ULNAR
PSEUDOARTHROSIS.
•SEGMENTALEXCISION OF ULNA
AT THE LEVELOF ULNAR NECK
UPTO 10- 15 MM
•ULNAR HEAD IS RETAINED
AND FUSED VIA SCREWSTO
THE SIGMOID NOTCH

48. SALVAGE PROCEDURES
• SYMPTOMATIC COMMINUTED I/A FRACTURESAND DISTAL RADIAL MALUNIONS THAT DEVELOP
POSTTRAUMATIC ARTHRITIS
1. TOTAL WRIST ARTHRODESIS
• TREATMENT OFCHOICE IN YOUNG PATIENTS
• STABLEPAINLESSWRISTACHIEVED; THOUGH MOTION ISSACRIFICED DISTAL
ULNA USUALLYRESECTEDALONG WITH ARTHRODESIS
2. PARTIAL WRIST ARTHRODESIS
• ARTHRITIS LIMITED TO RADIOCARPELJOINT ONLY
3. RADIOSCAPHOLUNATE ARTHRODESIS
• IF ENTIRERADIOCARPELJOINT IS INVOLVED
4. RADIOLUNATE ARTHRODESIS
• DIE- PUNCH INJURYOFLUNATE FACETA/W ARTHRITIS

49. THANK YOU