The records of patients who had had a reconstruction of a malunited fracture of the distal end of the radius were collected from the practice of the senior one of us (J. B. J.) in consecutive reverse chronological order beginning with patients who had had the procedure in 1992 and ending with those managed in 1984. Ten patients had had a reconstruction within fourteen weeks (average, eight weeks; minimum, six weeks) after the original injury and ten, a delayed reconstruction (average, forty weeks after the injury; range, thirty to forty-eight weeks).
Early Reconstruction
Nine men and one woman, with an average age of forty-two years (range, twenty to sixty-five years), had an early reconstruction (Table I). The left hand was involved in six patients and the right, in four; four patients had involvement of the dominant limb. Four of the ten patients had bilateral injury of the upper extremity. Four patients were laborers, three had a white-collar job, one was a photographer, one was a student, and one was a general surgeon. The mechanism of injury was a fall from a height for five patients, a fall from standing for two, a motor-vehicle accident for two, and a skiing accident for one. Nine patients had a metaphyseal fracture with dorsal displacement (a Colles fracture), and one had a volar shear fracture with a displaced lunate facet and subluxation of the radiocarpal joint10. Seven of the patients also had an impacted articular fracture. The original treatment of eight of the dorsally displaced fractures consisted of closed reduction and application of a cast; the ninth was treated with closed reduction and external fixation. The volar shear fracture was treated with open reduction and internal fixation.
The indications for early reconstruction were radiographic findings that had been determined to be predictive of a poor functional outcome in previous studies. These included a fracture with a dorsal tilt of the distal radial articular surface of more than 20 degrees11,13,24,26,27; a fracture with articular displacement of more than two millimeters20; and a displaced fracture with either fixed carpal malalignment (a lunate with more than 15 degrees more dorsal angulation than that in the contralateral, uninvolved wrist, as seen on a lateral radiograph), incongruity of the distal radio-ulnar joint (with complete dissociation of the distal aspect of the ulna from the sigmoid notch of the distal aspect of the radius as a result of shortening or angulation), or subluxation of the radiocarpal joint associated with a displaced intra-articular fracture of the distal aspect of the radius13,21,26,27,31.
Seven of the nine dorsally displaced fractures were treated with early reconstruction primarily on the basis of excessive dorsal tilt. The remaining two dorsally displaced fractures were so treated on the basis of intra-articular malreduction. For the volar shear fracture, the indications for early reconstruction included a missed and malreduced fracture of the lunate facet and residual subluxation of the radiocarpal joint.
Four of the ten extremities were no longer in a cast or a splint at the time of the reconstruction, and the preoperative functional assessment was documented. The average time from removal of the cast or splint to the final preoperative functional assessment was five weeks (range, two to eight weeks). On the average, the four patients had extension of the wrist of 33 degrees, flexion of 33 degrees, ulnar deviation of 10 degrees, radial deviation of 9 degrees, pronation of the forearm of 53 degrees, and supination of the forearm of 60 degrees, compared with 63, 61, 30, 16, 80, and 80 degrees, respectively, for the contralateral wrist. The average grip strength for the four extremities, as determined with a Jamar dynamometer (Asimow Engineering, Los Angeles, California), was seventeen kilograms, compared with fifty kilograms on the contralateral side.
All ten patients were dissatisfied with the appearance of the wrist. Pain was assessed at the radiocarpal, radio-ulnar, and mid-carpal joints for the four patients who were no longer wearing a cast or a splint, and it was graded as mild, moderate, or severe. Three patients had moderate pain and one had mild pain at the radiocarpal joint. Two patients had severe pain and two had mild pain at the radio-ulnar joint.
On the preoperative radiographs, dorsal angulation averaged 21 degrees (range, 0 to 45 degrees); radial shortening, six millimeters (range, two to eleven millimeters); and radio-ulnar inclination, 11 degrees (range, 5 to 20 degrees). All seven patients who had intra-articular involvement had involvement of the lunate facet.
Radiographs of the contralateral wrists of all patients were made for comparison during preoperative planning. A dorsal exposure was used for nine patients and a volar exposure, for one. An intraoperative, indirect reduction was performed with a distractor in four patients. In all ten patients, the osteotomy was performed through the fracture—both metaphyseal and intra-articular components. Autogenous cancellous iliac-crest bone graft was used in all patients. All patients also had internal fixation with a T-shaped plate (Figs. 1-A, 1-B, 1-C, 1-D, 1-E through 1-F), supplemented with Kirschner wires when necessary, and one patient had additional fixation with a one-quarter tubular plate.
Postoperatively, six wrists were immobilized in a splint and four were immobilized in a cast for an average of five weeks (range, four to six weeks). All ten patients followed a program of occupational therapy for six to twelve weeks after removal of the cast or splint.
There were no perioperative complications. One patient had a rupture of the extensor pollicis longus tendon twelve weeks after the procedure and needed a tendon transfer.
Late Reconstruction
Six women and four men, with an average age of thirty-eight years (range, twenty to sixty years), had a delayed osteotomy (Table II). The right hand was involved in four patients and the left, in six; four patients had involvement of the dominant limb. None of the patients had an injury of the contralateral upper extremity. Four patients were laborers at the time of the injury, one was a homemaker, and five had a white-collar job. The mechanism of injury included a fall from a height for five patients, a fall from standing for three, and a motor-vehicle accident for two.
Seven patients had a metaphyseal fracture (with dorsal angulation in six patients and with volar angulation in one); two had a multifragmented, comminuted intra-articular fracture with a dorsally displaced metaphyseal component (one of these patients had an open injury); and one had a volar shear fracture with displacement of the lunate facet.
The initial treatment consisted of closed reduction and application of a cast for eight patients; closed reduction and external fixation for one; and closed reduction, pin fixation, and application of a cast for one.
The preoperative examination of the injured extremity revealed, on the average, flexion of the wrist of 34 degrees, extension of 33 degrees, ulnar deviation of 7 degrees, radial deviation of 25 degrees, pronation of the forearm of 62 degrees, and supination of the forearm of 37 degrees, compared with 62, 63, 30, 15, 80, and 80 degrees, respectively, for the contralateral extremity. The average grip strength was fourteen kilograms for the injured extremity, compared with thirty-six kilograms for the contralateral extremity.
Five patients had mild pain, four had moderate pain, and one had no pain at the radiocarpal joint. Three patients had mild pain, five had moderate pain, and two had no pain at the radio-ulnar joint. All ten patients were dissatisfied with the appearance of the wrist.
The preoperative radiographs revealed an average dorsal angulation of 19 degrees (range, 0 to 35 degrees) in the eight patients with dorsal displacement and an average volar tilt of 24 degrees in the two patients with volar displacement. Radial shortening averaged eleven millimeters (range, six to eighteen millimeters) and radio-ulnar inclination, 5 degrees (range, -10 to 20 degrees). Two patients had intra-articular involvement with displacement of the lunate facet.
The decision to proceed with late operative reconstruction of a malunited fracture of the distal end of the radius was based on pain and limitation of function rather than on radiographic parameters. Patients who had some combination of pain at the radiocarpal or distal radio-ulnar articulation, limited motion due to dysfunction of the distal radio-ulnar joint, and reduced grip strength had a distal radial osteotomy and corticocancellous bone-grafting8,10-12 for anatomical reconstruction of the distal end of the radius in an attempt to improve function.
A dorsal exposure was used for eight patients and a volar exposure, for two. Five patients had intraoperative, indirect reduction with use of a distractor. All of the patients had a metaphyseal osteotomy at a predetermined osteotomy site approximately one and one-half centimeters proximal to the radiocarpal joint. In addition, two patients had an osteotomy through an intra-articular malunion. All patients were managed with a corticocancellous trapezoidal graft and internal fixation with a T-shaped plate (Figs. 2-A, 2-B, 2-C, 2-D through 2-E).
Postoperatively, five extremities were immobilized in a cast and five were immobilized in a splint for an average of five weeks (range, four to six weeks). All of the patients participated in a rehabilitation program for six to twelve weeks after removal of the cast or splint.
The only early complication was continued pain at the donor site of the iliac-crest bone graft in one patient. One other patient had delayed healing of the osteotomy site and needed a second procedure involving additional bone graft and application of a second plate.
Follow-up
All patients were personally followed throughout the course of treatment and recovery by the senior one of us. The follow-up examinations included documentation of the patient's subjective assessment of the result, physical examination, measurement of grip strengths, and follow-up radiographs. The result was assessed with use of the scale of Fernandez8 at the most recent examination. All of the measurements reported here were made at the most recent follow-up examination. According to the scale of Fernandez, an excellent result indicates that the patient has no residual pain or deformity, normal or nearly normal motion, and grip strength that is not less than 80 per cent of normal. A good result indicates that the patient has no or mild pain, no deformity, moderate limitation of motion (not less than 65 per cent of normal), and grip strength that is not less than 70 per cent of normal. A fair result indicates that the patient has moderate pain during work, mild deformity, motion that is 40 to 65 per cent of normal, and grip strength of 50 to 70 per cent of normal. Finally, a poor result indicates a failure of treatment, with persistent pain during work or daily activities, severe loss of motion (less than 40 per cent of normal), and grip strength that is less than 40 per cent of normal or that is associated with stiffness of the digits.
The Fernandez point-score system was also used9. With this system, residual pain in the radiocarpal and distal radio-ulnar joints, flexion and extension of the wrist, rotation of the forearm, and grip strength are assessed and points are assigned as follows. At each of the two wrist articulations, severe pain was assigned 0 points; moderate pain, 1 point; mild pain, 2 points; and no pain, 4 points. A flexion-extension arc of 130 to 140 degrees at the wrist was given 4 points; 100 to 130 degrees, 3 points; 80 to 100 degrees, 2 points; and less than 80 degrees, 1 point. Rotation of the forearm of 160 to 180 degrees was assigned 4 points; 140 to 160 degrees, 3 points; 120 to 140 degrees, 2 points; and less than 120 degrees, 1 point. Grip strength of at least 80 per cent of that of the uninvolved hand received 4 points; 65 to 70 per cent, 3 points; 40 to 65 per cent, 2 points; and less than 40 per cent, 1 point.
According to the point-score system9, a total score of 18, 19, or 20 points is excellent; 15, 16, or 17 points is good; 12, 13, or 14 points is fair; and less than 11 points is poor.
Statistical Analysis
Statistical comparison of the time until the patients returned to work after the early reconstructions with the time until they returned after the late reconstructions was performed with use of the Mann-Whitney non-parametric comparison of continuous variables (Microsoft Excel; Microsoft, Seattle, Washington). The groups were compared with regard to both the time from the injury to the patients' return to work and the time from the operation to the patients' return to work.
Early Reconstruction
The average duration of follow-up was forty-eight months, with a range of twenty to 120 months (Table I). The average time to radiographic union of the osteotomy site was five weeks (range, four to eight weeks). All nine patients who had been employed before the injury returned to their previous occupation. The remaining patient was a student. The patients returned to their preoperative level of work an average of twenty weeks (range, three to fifty-four weeks) after the operation and an average of twenty-nine weeks (range, eleven to sixty weeks) after the injury. The four patients who were laborers returned to work an average of thirty-three weeks (range, sixteen to sixty weeks) after the injury.
One patient had mild pain in the radiocarpal joint, and three patients had the plate removed because of synovitis of the overlying extensor tendons.
At the most recent follow-up examination, extension of the wrist averaged 52 degrees; flexion of the wrist, 45 degrees; ulnar deviation, 24 degrees; and radial deviation, 12 degrees. The average pronation of the forearm was 79 degrees and the average supination, 77 degrees.
The average grip strength increased from seventeen kilograms preoperatively to forty-two kilograms post-operatively. Only one patient had a grip strength that was less than 80 per cent of that on the contralateral side. However, injuries involving the contralateral upper extremity in four of the patients makes comparison with the contralateral side less reliable.
The most recent radiographs revealed an average dorsal tilt of -1 degree (range, -5 to 5 degrees). There was virtually no radial shortening, and the average radio-ulnar inclination was 20 degrees (range, 15 to 30 degrees) (Table I).
Seven patients had an excellent result and three had a good result, according to the scale of Fernandez8. According to the Fernandez point-score system9, there were seven excellent results, two good results, and one fair result (Table I).
Late Reconstruction
The average duration of follow-up was thirty-four months, with a range of twenty-four to forty-eight months (Table II). The average time to radiographic union was ten weeks (range, six to twenty-eight weeks). Of the nine patients who were working outside the home before the injury, eight returned to their previous occupation, at an average of ninety-five weeks (range, forty-six to 144 weeks) after the injury and fifty-five weeks (range, four to ninety-six weeks) after the osteotomy. The patient who did not return to work was a sixty-year-old female bookkeeper. The four patients who were laborers returned to work at an average of 110 weeks after the injury and seventy weeks after the osteotomy.
One patient had mild pain in the radiocarpal joint, and one had mild pain in the distal radio-ulnar joint. One patient had mild residual deformity. Two patients had the plate removed because of synovitis of the overlying extensor tendons.
Extension of the wrist averaged 45 degrees; flexion of the wrist, 42 degrees; ulnar deviation, 28 degrees; and radial deviation, 13 degrees. The average pronation of the forearm was 77 degrees and the average supination, 68 degrees. The over-all range of motion was decreased in five patients, with one patient having a decrease to less than 65 per cent of that on the contralateral side.
The average grip strength increased from fourteen kilograms preoperatively to twenty-five kilograms postoperatively. Seven patients had a grip strength that was less than 80 per cent of that on the contralateral side.
Follow-up radiographs revealed an average dorsal tilt of 2 degrees (range, 0 to 10 degrees), virtually no radial shortening, and an average radio-ulnar inclination of 18 degrees (range, 8 to 26 degrees) (Table II). One patient had mild radiocarpal osteoarthrosis.
The result was excellent in one patient, good in seven, and fair in two, with use of the scale of Fernandez8. With use of the Fernandez point-score system9, there were two excellent, six good, and two fair results (Table II).
Statistical Analysis
The difference between the results of the early and late reconstructions with regard to the average time from the injury to the patients' return to work (p < 0.001, two-tailed) and from the operation to their return to work (p = 0.01, two-tailed) were significant with use of the Mann-Whitney test.
With few exceptions (primarily in older patients with low functional demands), maintenance of adequate function of the wrist after fracture of the distal end of the radius has been shown to depend on accurate restoration of an anatomical position3,15,16,19,23,24,32. Angular deformity and shortening of the distal end of the radius lead to altered load-bearing by articular surfaces (a pre-osteoarthrotic condition)24,26,27, adaptations of the radiocarpal and mid-carpal joints that contribute to instability and pain (as a result of synovitis and osteoarthrosis)11,19,21,28,29,31, incongruity of the surfaces of the distal radio-ulnar joint4,5,11,13,14,25,32, and impingement and tightness in the triangular fibrocartilage complex11. Progressive damage of these structures leads to pain and loss of motion. When osteoarthrotic changes become severe, salvage procedures become necessary11,17. Early intervention to prevent these sequelae by means of a corrective osteotomy can be expected to provide a more predictable outcome than late correction. Correction in the early stage of malunion may allow the patient to avoid these maladaptations altogether. In the present investigation, early reconstruction of malunited fractures of the distal end of the radius for which clinical and radiographic parameters were thought to be predictive of a poor functional outcome was found to optimize function of the wrist and to minimize pain as successfully as traditional delayed correction of mature malunions with use of radial osteotomy and corticocancellous bone-graft interposition. This approach for early malunions was technically easier and resulted in a shorter total duration of disability.
While early reconstruction of malaligned fractures of the distal end of the radius is not customary, it is by no means a new concept. In 1882, Little reported on his experience with refracture (or "forcible realignment") of the distal end of the radius as late as six weeks after injury22 and noted that Dupuytren had also used this technique7. In 1925, Speed reported good results with the early operative correction of malunited fractures of the distal end of the radius by opening of the original fracture site29.
The indications for early operative reconstruction were primarily articular malreduction and dorsal angulation of more than 20 degrees. In contrast, the radiographic parameters measured in the patients being managed with a late reconstruction on the basis of functional limitation and pain were less consistent. Of note, a substantial amount of shortening of the radius was common in the patients selected for late reconstruction (five patients had at least ten millimeters of radial shortening). Both cohorts were made up of young patients (on the average) who had relatively high functional demands. The fact that four patients who had early reconstruction had had bilateral injury of the upper extremity may have biased our use of the first over-all assessment scale of Fernandez8, as we relied on comparison with the contralateral wrist. The Fernandez point-score system9, however, is not subject to this bias.
The most appealing advantage of the early reconstructive procedure proved to be the facility of corrective osteotomy when performed in the early stages of malunion. In each patient, it was possible to visualize the original fracture planes by removing the maturing callus. This facilitated repositioning not only in the sagittal and coronal planes but also in the horizontal plane, where malrotation is common and is often difficult to judge in a mature malunion18. Restoration of the precise relationship of the distal radial fragment to the ulna (and thus restoration of the integrity of the distal radio-ulnar joint) was easier when it was performed before the soft-tissue restraints of this articulation had become non-compliant. Use of autogenous cancellous bone obtained from the iliac crest with use of trephine core needles (as opposed to the corticocancellous graft needed for reconstruction of a mature malunion) to fill in the re-created fracture site resulted in decreased donor-site morbidity and more rapid healing. The capsular and surrounding soft-tissue contracture was more easily overcome in every patient when the reconstruction was performed at an earlier stage.
The clinical and radiographic parameters improved postoperatively in all twenty patients. The over-all functional ratings were slightly better after the early reconstructions than they were after the late ones. The greater prevalence of pain, limitation of motion, and decreased grip strength in the patients who had had a late reconstruction reflected, to some degree, the soft-tissue maladaptation that was prevalent in this cohort. Capsular, ligamentous, and tendinous structures contract to adjust to their altered orientation. It can be expected that, after ske-letal alignment is restored, the contracted capsular and ligamentous structures will limit motion and the maladapted tendons will have lost mechanical advantage, resulting in decreased grip strength.
The most important distinction between the postoperative course after early reconstruction and that after late reconstruction was with regard to the time to the patients' return to work. This parameter reflects loss of productivity, lost wages, Workers' Compensation costs, and the psychological impact of prolonged disability, all of which are minimized by the early return to work afforded by early reconstruction of a distal radial malunion.
It can be argued effectively that some patients who have a deformity may not have long-term dysfunction and that early intervention has the potential of being premature or unnecessary, not only exposing the patient to potential complications but also adding to costs and prolonging disability. However, the dependence of optimum function on accurate anatomical restoration has been well documented. A patient who has high functional demands (regardless of age) is likely to need a corrective osteotomy after malunion of a distal radial fracture. Considering the relative benefits of early reconstruction documented here, we believe that it should be considered for patients who have an early malunion of a fracture of the distal end of the radius.