The Journal of Hand Surgery (European Volume, 2009) 34E: 2: 160165

SAGITTAL ROTATIONAL MALUNIONS OF THE DISTAL RADIUS: THE ROLE OF PURE DEROTATIONAL OSTEOTOMY
F. DEL PINAL, F. J. GARCIA-BERNAL, A. STUDER, J. REGALADO, H. AYALA and L. CAGIGAL stica y de la Mano, Private Practice and Hospital Mutua Montanesa, Santander, Spain Instituto de Ciruga Pla

Sagittal rotational malunion after distal radius fractures was identied 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 posterioranterior 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 lled 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 1.5 mm, becoming identical to the opposite side. A pure derotational osteotomy corrected the apparent shortening of the radius and restored the volar tilt.
Keywords: Distal radius, Fracture, Malunion, Osteotomy, Bone graft

Malunion after a distal radius fracture usually occurs with dorsal tilting and radial shortening. The tilt is easily measured on the lateral radiograph, and the shortening on the posteroanterior lm. In some dorsally tilted malunions the volar cortex acts as a hinge point at the fracture line, and the distal fragment rotates on it, but does not translate. This occurs if there is only dorsal comminution: the distal fragment, unsupported dorsally, pivots on the volar cortex slowly rotating in the cast (Jenkins, 1989), or when the reduction was insufcient from the beginning. This represents a sagittal rotational malunion, and there is no shortening despite the appearance on a posterioranterior radiographic view (Fig 1). Such a sagittal rotational malunion can be recognised on the lateral radiograph, by the preservation of the volar cortex and by having the anterior rim of the radius longer than the head of the ulna, conrming the absence of shortening (Fig 2A). This deformity can be corrected by a derotation osteotomy alone rather than the more complex three-dimensional reconstruction (Figs 2BD). The purpose of this paper is to present the surgical technique and results of derotational osteotomy in eight patients with rotational malunion of a distal radius fracture.

METHOD All operations were performed under axillary block on an out-patient basis. The arm was exsanguinated and tourniquet applied. Cancellous bone from the olecranon was rst harvested through a 2.5-cm transverse incision.

The cavity was lled with Surgicels, and the wound was closed in a single layer with a 3/0 subcuticular nylon. The malunion site was approached through a 6 to 8 cm incision radial to the exor carpi radialis sheath (FCR) with a 10 mm radially directed back cut in the proximal wrist crease. The space between the FCR and radial vessels was developed. The pronator quadratus was then elevated subperiosially and reected ulnarwards. This exposed the malunion site and the radius. Dissection was continued to the dorsum of the radius, going deep to the brachioradialis. The thickened periosteum was elevated, and divided proximal to the extensor tendon compartments making several transverse cuts, until the tendons were exposed. Adequate reduction of the distal fragment may not be possible without division of this thickened periosteum as it acts as a restraint. The locking plate was then applied volarly, prior to the osteotomy, as recommended by Prommersberger and Lanz (2004). The transverse part of the plate was placed distal to the hinge point of the malunion. K-wires helped ascertain that the distal pegs were subchondral for a strong hold (Fig 3). When the surgeon was satised with the position, all the distal screws and pegs were inserted. At the end of this step of the operation, the plate should form an angle with the radial shaft in the sagittal plane equal to the angle calculated preoperatively on the lateral radiograph to achieve correction of the deformity. To avoid loss of volar cortical bone when using an oscillating saw, the osteotomy was performed with a 1-mm K-wire. A series of perforations parallel to the

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Fig. 1 Malunited distal radius fracture with true dorsal tilting and apparent shortening of the radius. (A) The sclerotic rim appears to show a positive 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 be seen 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 PA view as in (A), the volar lip (with dots) is clearly distal to the head of the ulna conrming the inaccuracy of the variance measured in (A). A ne grey line has been drawn tangentially to the ulnar dome across all the radiograms. A ne 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 the original fracture line can be seen (arrow), attesting to preservation of the volar cortex length. The distal volar rim can be seen distal to the head of the ulna conrming the ulna minus variance (stippled in black). (B) The hinge point will be used as the rotation point of the distal fragment. (C) Pure rotation on the fulcrum will correct dorsal tilting preserving the radial length. (D) The result on this patient. A ne grey line has been drawn tangentially to the ulnar dome across all the radiograms. A ne black line marks the volar rim of the radius.

articular surface, to the dorsal cortex, were made along the exact hinge point of the malunion (Fig 4). After the K-wire perforations were completed, the distal radius, xed with the plate, was bent dorsally to break the weakened palmar cortex. Several attempts were needed in most cases, and in some an oscillating saw was required to cut the very sturdy ulnar cortex.

The distal radius with its attached plate was then reduced to the shaft of the radius, by pushing the distal fragment volarly, as in a closed distal radius fracture reduction. The use of a lamina spreader to distract the dorsal tissues helped achieve a gentle reduction. We avoided the forceful use of bone clamps to bring the stem of the plate to the shaft of the radius as we feared

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Fig. 3 The plate has been provisionally stabilised with K-wires to the distal fragment. An intravenous needle, used for reference, will help to place the plate as distal as possible, and to keep the ulnar K-wires subchondrally.

Fig. 4 Once the plate has been securely xed distally, osteotomy through the hinge point, is carried out. In order to preserve the length of the volar cortex intact, the osteotomy is performed with a 1-mm K-wire.

that the screws could pull out of the bone. Once the plate lay easily on the shaft, it was held temporarily by two bone clamps. Careful reduction of the fragments at the hinge point assured that the volar cortex continuity was restored; otherwise, shortening and incomplete volar tilt correction will ensue (Figs 5A and B). Additionally, in order to compensate for some collapse that may have occurred at the osteotomy site, the rst screw on the stem of the plate was placed eccentrically to distract the osteotomy and restore the normal radial length (Figs 5C and D). The dorsal bone gap was lled with the cancellous bone from the olecranon. The pronator quadratus was sutured over the plate, if possible. At the rst postoperative visit, 24 to 48 hours later, a removable splint was applied and the patient encouraged to start active range of motion exercises. After 4 to 6 weeks patients gradually discarded the splint. This operation was carried out in eight patients. There were three females and ve males, aged 23 to 60 years (mean 37 years). All but two patients were involved in heavy occupations prior to the accident. At the time of their referral 3.5 months to 3 years (mean 10 months) all were off work because of their wrist except for two patients, one of whom had reduced her work and sport activities due to wrist pain. Six patients were covered under workers compensation, and were on sick leave or involved in litigation. Seven patients had previously been treated in a cast and one had xation with K-wires. Patients conrmed an improvement in pain on a visual analogue 10 cm scale from 7.25 (range 69) preoperatively to 0.50 (range 02) at follow-up between 6 and 35 months. Active exionextension changed from

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Fig. 5 Effect of lack of volar cortex restoration is shown in a clinical case. (A and B) If the surgeon fails to appropriately engage the volar cortex (yellow circle), shortening and insufcient tilt correction will ensue. (C and D) After restoration of the volar cortex (white arrow), the length and the volar tilt of the radius have both improved.

a pre-operative arc of 971 (range 641401) to 1371 (range 1181501). Pre-operative forearm rotation arc was 1451 (range 1001801) and improved to 1751 (range 1601801). Grip strength measured with a Jamar dynamometer was 44% of the contralateral side preoperatively (range 3355%), and 95.5% at follow-up (range 86105%). At follow-up patients had a DASH score of 6 (range 016) compared to a pre-operative score of 54 (range 3874). Radiographically all osteotomies healed. A correction of the dorsal tilt of 261 (range 20361) was achieved postoperatively (average correction from 231 (201 to 291) to +31 (091)). Despite the fact that the radius was not lengthened, on the PA view, the ulnar variance improved an average of 3 mm (range 24 mm) by the derotation osteotomy (pre-operative ulna of +1.5 mm (range 03.5) to 1.5 mm (range 3 to +1.5) postoperative) (Fig 6), being identical to the contralateral side. In every case a standard exploratory dry arthroscopy followed the osteotomy (del Pinal et al., 2007). Dorsal synovitis was present in most patients, possibly as a part of triquetrum chondromalacia-ulnar detachment (Nishikawa et al., 2002), synovectomy was carried out as required. Three patients had ulnar styloid excision for impingement of a non-united ulnar styloid through a mini-open incision. One patient had arthroscopic reattachment of the TFCC at the fovea with a bone anchor (Atzei et al., 2005). One patient sustained a displaced olecranon donor site fracture, when she fell down a ight of stairs 22 days after surgery. The fracture was xed and iliac crest bone graft used. This patient fared the worst with a DASH score of 16. One patient had symptoms of carpal tunnel syndrome at follow-up and is being treated with a splint at night. DISCUSSION Some malunited radius fractures that appear shortened may have just healed in malrotation. Typically the

fracture was in most cases treated non-operatively. Despite the moderate deformities seen on plain radiographs, some patients may report deceptively severe symptoms, and can benet enormously from this simple osteotomy. True shortening, that occurs due to volar comminution or when the continuity of the volar cortex is lost, will not be corrected by the operation described in this paper (Fig 7). Restoration of the hinge point on the volar cortex is critical, as otherwise shortening and incomplete correction of the volar tilt will occur (Fig 5). Several authors recommend removal of the plate before carrying out the osteotomy (Henry, 2007; Malone et al., 2006; Prommersberger and Lanz, 2004). This can leave the distal segment unstable, making the reduction more difcult, and can jeopardise secure screw xation. We therefore recommend that the osteotomy is performed with the plate applied. While sagittal malalignment will be directly addressed by the operation, and any prono-supination deformity of the distal fragment will be corrected by the plate (Fernandez, 1993; Prommersberger et al., 2004), the technique of pure derotational osteotomy as presented here will not correct the loss of radial tilt. This can be considered a major drawback as the loss of radial inclination can compromise grip strength (Fernandez, 1993; Jenkins and Mintowt-Czyz, 1988). Conversely, Warwick et al. (1993) failed to correlate radial tilt loss with clinical outcome after Colles fractures, and Altissimi et al. (1986) only found a negative effect when the radial tilt loss was greater than 201 (less than 51 radial tilt). Furthermore, in Kienbocks disease radial closing wedge osteotomy has been recommended, without adverse effects reported at the 10-year follow-up (Wada et al., 2002). Although some spontaneous correction was also achieved with our technique, perhaps by the plate itself, the operation will not correct major (less than 51) loss of radial tilt. True shortening as well as dorsal tilting can lead to ulnar head overload and symptoms (Pogue et al., 1990; Short et al., 1987). The correction on the sagittal plane

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Fig. 6 Pure sagittal malunion. (A and B) Pre-operative; (C and D) 1 year after the operation.

obtained by the rotational osteotomy, together with the concomitant treatment of associated ulnar pathology detected by arthroscopy, was sufcient to correct the ulnar symptoms in this group of patients. The contribution of each one of them on the disappearance of the ulnar symptoms is unknown. Several papers have suggested that bone graft donor site morbidity can be avoided by the use of nonstructural bone grafting, or bone substitutes. The olecranon is a useful donor site even though one of our patients suffered a fracture after a fall 22 days after

surgery. We empirically now advise all patients when harvesting bone from the olecranon, to continuously wear an elbow protection as used by skateboarders for 5 weeks. Incomplete osteotomies have been previously suggested for distal radius fracture malunions (Fernandez et al., 2002; Jupiter and Fernandez, 2002). However, the clues to decide when to carry an incomplete osteotomy or a tridimensional reconstruction have not been clearly stated or are based on complicated methods. By identifying the hinge point on the lateral radiogram,

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Fig. 7 Schematic representation of the two main possible displacements, in the sagittal plane, after an extraarticular Colles fracture: Pure rotational malunion (above) and translational and rotational malunion (below), with the expected results by a derotational osteotomy. Complete correction of the deformity will be achieved by a derotational osteotomy if proper technique is carried out (above right). Conversely, a short radius will result if the technique is inaccurate, or if it is used to treat combined (translational and rotational) malunions (below right).

and ascertaining that the volar lip of the radius is distal to the ulnar head, the surgeon can be assured that the simpler incomplete osteotomy would correct the radius deformity. This study is preliminary because of the small number of patients and short follow-up. However, the results have been encouraging, and the radiological correction seems reproducible.
References
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with xed angle volar plating: a case series. J Hand Surg Am. 2006, 31: 36672. Nishikawa S, Toh S, Miura H, Arai K. The carpal detachment injury of the triangular brocartilage complex. J Hand Surg Eur. 2002, 27: 8689. del Pinal F, Garcia-Bernal FJ, Pisani D, Regalado J, Ayala H, Studer A. Dry arthroscopy of the wrist: surgical technique. J Hand Surg Am. 2007, 32: 11923. Pogue DJ, Viegas SF, Patterson RM et al. Effects of distal radius malunion on wrist joint mechanics. J Hand Surg Am. 1990, 15: 72127. Prommersberger KJ, Froehner SC, Schmitt RR, Lanz UB. Rotational deformity in malunited fractures of the distal radius. J Hand Surg Am. 2004, 29: 11015. Prommersberger KJ, Lanz UB. Corrective osteotomy of the distal radius through volar approach. Tech Hand Upper Extremity Surg. 2004, 8: 707. Short WH, Palmer AK, Werner FW, Murphy DJ. A biomechanical study of distal radial fractures. J Hand Surg Am. 1987, 12: 52934. Wada A, Miura H, Kubota H, Iwamoto Y, Uchida Y, Kojima T. Radial closing wedge osteotomy for Kienbocks disease: an over 10 year clinical and radiographic follow-up. J Hand Surg Am. 2002, 27: 17579. Warwick D, Prothero D, Field J, Bannister G. Radiological measurement of radial shortening in Colles fracture. J Hand Surg Eur. 1993, 18: 5052.
Received: 20 September 2007 Accepted after revision: 27 July 2008 Dr Francisco del Pinal, Dr Med, Calderon de la Barca 16-entlo, E-39002 Santander, Spain. Tel.: +34 942 364696; fax: +34 942 364702. E-mail: drpinal@drpinal.com, pacopinal@ono.com.

doi:10.1177/1753193408097324 available online at http://jhs.sagepub.com