Union with deformity is the most common complication following
a distal radial fracture1-5. The
deformity may be extra-articular, characterized by loss of length
and metaphyseal angulation; it may be intra-articular, involving
either the radiocarpal or the radioulnar joint, or both; or it may
be a combination of the two.
Surgical treatment of a symptomatic malunion of the distal part
of the radius has been recognized for more than 200 years. Resection
of the distal aspect of the ulna for the management of pain at the
distal radioulnar joint after a distal radial fracture, a procedure
attributed to Darrach after his description in 19136, had been suggested by Desault in 17917 and again by Moore in 18808. In 1937, Campbell described a corrective
osteotomy of the distal part of the radius with use of an interpositional bone
graft obtained from the distal part of the ulna9.
In 1945, Merle d’Aubigné and Joussement described
a multiple-facet curved osteotomy without the need for an interpositional
bone graft10. This concept is
currently being revisited and will be described.
A deformity following fracture of the distal part of the radius
is not necessarily symptomatic. In fact, it is not uncommon for
an older patient to have acceptable wrist and forearm function without
pain even when there is an apparent deformity. Therefore, impairment
of function rather than radiographic deformity is the reason to
treat a distal radial malunion, and, consequently, the patient’s
wrist and forearm function must be assessed.
The most common deformity following a malunited extra-articular
Colles type of fracture is the loss of the normal volar tilt of
the articular surface in the sagittal plane, loss of ulnar inclination in
the frontal plane, loss of length relative to the ulna, and rotational
deformity of the distal fragment11 (Fig. 1). In addition,
the distal fragment may be translated in either the sagittal or
the frontal plane. In a report on twenty-seven patients undergoing
a corrective osteotomy, Bilic et al. noted that more than half had
a translation of 3 mm of the distal fragment12.
A patient with a dorsal deformity of the distal radial fragment,
and loss of the normal volar tilt, will have loss of palmar flexion
and, on occasion, an increase in wrist extension. This malalignment
alters the force pattern across the wrist and can lead to posttraumatic arthrosis13-18. Dorsal tilt of the distal articular
surface of the radius not only alters the force distribution within
the radiocarpal joint but also increases the load on the distal
part of the ulna14,19-21. In addition,
radiocarpal instability can develop in a patient with a dorsally
displaced carpus, even when the intercarpal ligaments are intact.
This instability may produce pain at the radiocarpal articulation.
The dorsal deformity can also result in problems at the midcarpal joint21-24. An extrinsic midcarpal dynamic
instability has been noted in some patients. These patients have
a painful and, at times, audible subluxation of the midcarpal joint
with active ulnar deviation of the wrist while the forearm is pronated22. In patients with laxity of the
intercarpal and radiocarpal ligaments, continued stress on the midcarpal
joint results in synovitis, ligamentous stretching, and increased
intercarpal deformity25.
A dorsal deformity of the distal radial articular surface can
also produce a fixed carpal malalignment—that is, a dorsal
intercalary segment instability. This instability, associated with
a dorsally angulated malunion of a distal radial fracture, can be
classified into two categories26:
Type I: A "lax" reducible
dorsal carpal malalignment that is improved, or even totally corrected,
by a distal radial osteotomy. This type is more likely to be found
in young individuals with lax ligaments and a good range of wrist mobility
despite the deformity (Figs. 2-A, 2-B, 2-C, 2-D, and 2-E).
Type II: A dorsal intercalary segment instability that
is "fixed" and does not improve after correction
of the distal radial malunion (Figs. 3-A, 3-B, 3-C, and 3-D).
Malunions of the distal part of the radius that are associated
with loss of the normal ulnar inclination in the frontal plane may
position the carpal tunnel in a radial direction, angulating the flexor
tendons and decreasing their mechanical advantage. This contributes
to diminished strength. Dorsal deformity has been associated with alteration
of extensor tendon function27 as
well as an increase in the intracompartmental pressure in the carpal
tunnel.
Malunited Smith fractures (palmar displacement of the distal
articular fragment) have an increased palmar tilt and pronation
deformity of the distal fragment28.
Disruption of the distal radioulnar joint is quite common. In contrast
to the dorsally directed deformity, midcarpal instability and/or
carpal malalignment is less often observed.
The distal radioulnar joint may also be impaired as a result
of the distal radial deformity producing an incongruity of the sigmoid
notch articulation with the ulnar head8,18,29-31.
Radial shortening in relation to the distal part of the ulna can
lead to tightening of the triangular fibrocartilage complex and
impedance in the arc of forearm rotation. Long-standing radial shortening
has also been shown to result in impaction of the ulnar head onto
the lunate with attrition wear in the center of the triangular fibrocartilage complex.
Several patterns of intra-articular malunion involving the radiocarpal joint
have been identified13,32,33.
Posttraumatic collapse of the lunate facet (a die-punch fracture)
can affect the position of the lunate, usually in association with
an intercalary segment instability. A malunited shearing Barton
fracture, in addition to having intra-articular incongruity, leads
to chronic volar or dorsal radiocarpal subluxation. The potential
for the development of secondary arthritis is increased by these fractures,
which heal with incongruity of the distal radial articular surface
in the presence of intercarpal ligament injury34.
A number of factors must enter into the decision regarding the
surgical treatment of a distal radial malunion. These factors include
the degree of discomfort with use of the wrist, the clinical appearance,
the radiographic findings, and most importantly the patient’s expectations
with regard to the outcome. The physician should identify the location
of the discomfort, the presence or absence of instability of the
distal radioulnar joint, the range of motion of the wrist and forearm,
and the grip strength compared with that on the contralateral side.
There are no fixed radiographic parameters with which to determine
surgical indications for corrective osteotomy. In an analysis of
sixty-four malunions of the distal part of the radius, Fourrier
et al. concluded that the lower limits of deformity at which symptoms
are likely to develop include a radial deviation of the distal fragment
of between 20° and 30°, a dorsal tilt in the sagittal plane of between
10° and 20°, and shortening of between 1 and 2 mm35.
Additional experimental evidence suggests that a dorsal tilt of
between 20° and 30° should be considered as a prearthrotic condition14,15,21 (Table I).
The goal of a corrective osteotomy is to reorient the distal
articular surface of the radius in order to restore normal load
distribution across the wrist joint, reestablish the normal kinematics
of the midcarpal and radiocarpal joints, and restore the anatomic
orientation of the distal radioulnar joint11.
Our combined experience with nearly 200 corrective osteotomies has
shown that, when these goals were accomplished, motion and function
of the wrist and distal radioulnar joints as well as patient acceptance
of the outcome were improved in the majority of cases. The contraindications
to surgical correction of a deformity include advanced degenerative
changes in the radiocarpal and intercarpal joints, fixed carpal malalignment,
limited functional disability, and advanced osteoporosis26 (Table I).
We have performed the corrective osteotomy as soon after a fracture
as it has been decided that the patient meets the criteria and the
swelling has subsided. An advantage of earlier intervention is that
the deformity can be corrected through the immature callus of the
healing fracture. This minimizes soft-tissue contracture and dysfunction of
the distal radioulnar joint, which tend to develop over time. Early
intervention also limits the economic and physiologic impact of
the deformity.
The timing of the intervention was evaluated in a study comparing
two groups of patients who had had a corrective osteotomy of a distal
radial malunion36. One group of
ten patients had had the osteotomy at an average of 8.2 weeks after
the initial injury, and a comparable group of ten patients had had
the osteotomy at an average of 39.9 weeks after the fracture. The
overall functional and radiographic outcomes were similar, but earlier
intervention reduced the total duration of disability. The time until
the patient returned to work after the initial injury averaged twenty-one weeks
in the early-intervention group compared with seventy weeks in the late-correction
group.
Standard biplanar radiographs of both wrists are adequate for
the planning of the operative treatment of most deformities11,37. Comparison with the uninjured
wrist is crucial to the understanding of carpal alignment, ulnar
variance, and inclination of the distal radial articular surface in
the sagittal plane16,17,38. Computerized tomography can be used
to evaluate instability or incongruence of the distal radioulnar
joint or rotational malalignment of the distal part of the radius39-41. Rotation of the distal fragment
can be accurately determined by superimposition of tracings of symmetrical
computerized tomography slices of both forearms obtained in neutral
rotation. The proximal computerized tomography slice should include
the bicipital tuberosity and the distal slice should include Lister’s
tubercle to serve as reference points39.
The difference between the measurements on the uninjured and injured sides
represents the amount of rotational malalignment. Three-dimensional
reformatting of computerized tomography images is especially useful for
patients who need both intra-articular and extra-articular corrections32,42-44.
Bilic et al. demonstrated an effective use of computer-assisted
modeling in the planning of corrective osteotomies12. The use of computer-assisted design and
computer-assisted manufacturing technology has facilitated the construction
of three-dimensional solid models45.
The specific surgical technique depends on a number of factors:
the type and direction of the deformity, the presence of intra-articular
displacement, associated soft-tissue conditions, distal radioulnar
dysfunction, and the surgeon’s preference11,31,33,38,41,46-49.
Shortening of the radius in relation to the ulna is a common
feature of most malunions; therefore, an opening-wedge osteotomy
(transverse in the frontal plane and parallel to the articular surface
in the sagittal plane) is the most frequently performed procedure11,31,37,46. Lengthening of the radius
as much as 12 mm, restoration of the volar tilt in the sagittal
plane, and rotational correction in the horizontal plane are all
possible. The defect created by this approach can be filled with
autogenous iliac-crest bone graft.
Dorsally Displaced Deformity
A 5 to 7-cm dorsal incision beginning 2 cm distal to Lister’s
tubercle and extending proximally provides excellent exposure. We
open the extensor retinaculum between the second and third compartments,
and we subperiosteally elevate the fourth compartment off of the
radius. The osteotomy is usually done 2 cm from the distal radial articular
cartilage. The sagittal plane of the articular surface is determined
by placing a fine Kirschner wire into the radiocarpal joint parallel
to the articular surface of the radius. A 2.5-mm Kirschner wire
is drilled into the radius on both sides of the intended osteotomy site.
The angle between these two wires should be the planned angle of
correction in the sagittal plane. After the osteotomy is made, the
wire in the distal fragment can be used to help to manipulate that
fragment into correct alignment and then the wires can be connected
with a small external fixator frame to maintain the correction. Unless
the radius needs to be lengthened >12 mm, the osteotomy
should not extend completely through the volar cortex.
The osteotomy is made with a thin blade on an oscillating saw.
With use of a lamina spreader, the osteotomy site is opened dorsally
and radially, and the two Kirschner wires are connected with a small
frame. Complete tenotomy or z-lengthening of the brachioradialis
tendon can be done to help to gain length when a deformity is characterized
by extreme radial deviation and shortening.
Use of a contoured trapezoid-shaped corticocancellous iliac-crest
graft has been recommended to fill the metaphyseal defect created
by the osteotomy, but we use a cancellous graft to fill the defect
now that newer plates that allow screws to be placed in orthogonal
directions are available (Fig. 4). Cancellous graft more readily
fills the three-dimensional defect created by the osteotomy, is
incorporated more rapidly, and limits donor-site morbidity as the
cancellous bone can be harvested with trephine biopsy needles (Figs. 5-A, 5-B, 5-C, 5-D, 5-E, and 5-F).
Another option for the stabilization of the site of the corrective
osteotomy is an external fixator with the pins placed in the distal
fragment rather than in the metacarpals. This allows postoperative adjustment
should the restoration of length or alignment prove to be inadequate48.
A number of investigators have utilized computer-generated data
and/or computerized tomography scans to develop a more
accurate preoperative representation of the deformity12,39. The
better the surgeon’s understanding of the deformity, the
simpler the operation. Angular deformity in the frontal and sagittal
planes can be determined by superimposition of orthogonal radiographs
of the injured and normal wrists. Rotational deformity can be determined by
the comparative computerized tomography scan technique described by
Bindra et al.39. On the basis
of these data, an osteotomy can be created by opening the dorsal
and radial sides hinging on the volar and ulnar sides of the metaphysis26. The precise center of rotation
can be determined preoperatively. The osteotomy is done so that
the center of rotation lies in, on, or outside the margins of the
radial cortex. When the center of rotation needs to be within the
bone margins, an incomplete opening-wedge osteotomy is necessary.
When the center of rotation needs to be away from the bone, a complete
osteotomy with lengthening and insertion of a corticocancellous
iliac-crest bone graft is required. When the center of rotation needs
to be inside the bone and lengthening is not needed, a "rocking" type
of osteotomy (opening on one side and closing on the other) is done
(Figs. 6-A, 6-B, and 6-C). When a rotational
correction is required, the osteotomy line must be perpendicular
to the axis of the distal fragment. Two "reference" Kirschner wires
should be placed subtending the planned corrective rotational angle. Creating
the osteotomy from radial dorsal to ulnar palmar allows the interposed
graft to be a simple wedge rather than a more complicated trapezoidal wedge.
Palmarly Displaced Deformity
A classic volar Henry approach is used to expose the distal part
of the radius for a corrective osteotomy of a palmarly angulated
malunion. The malunion is exposed subperiosteally by reflecting
the pronator quadratus muscle to the ulnar side. The osteotomy is done
at the site of the original fracture, and the distal fragment is
then extended and rotated into the correct alignment. The application
of a T-shaped plate facilitates the fixation of a rotational correction.
The correction restores the alignment of both the radiocarpal and the
distal radioulnar joint (Figs. 7-A, 7-B, 7-C, and 7-D). When the distal fragment has
united in palmar flexion and is also shortened and extremely radially
angulated, tenotomy or z-lengthening of shortened wrist flexors
may be required to achieve the desired correction.
We reported our experience with opening-wedge osteotomy for the
treatment of a malunited volarly displaced fracture of the distal
part of the radius in twenty-five patients28.
The average volar inclination was 24°, the average ulnar variance
was 5 mm, and the average ulnar inclination of the articular surface
of the distal part of the radius was 14°. At an average of sixty-one
months after the osteotomy, the functional result was rated as very
good in ten patients, good in eight, fair in three, and poor in
four. The volar inclination averaged 5°, ulnar variance averaged
0 mm, and ulnar inclination averaged 22°. The grip strength improved
from an average of 17 kg to an average of 30 kg. Wrist extension improved
from an average of 25° to an average of 55°.
The indications for correction of an intra-articular malunion
depend upon the anatomy of the deformity as well as the duration
since the original injury17,33.
If the patient presents with an intra-articular malunion within
six months after the injury, our preference is to correct the deformity.
The deformities that are most suitable for correction are malunited
radial styloid fractures, dorsal or volar shearing (Barton) fractures, and
dorsal die-punch fractures of the lunate facet (Fig. 8-A, 8-B, 8-C, 8-D, 8-E, 8-F, 8-G, 8-H, 8-I, 8-J, 8-K, and 8-L).
Osteonecrosis of the articular components is a risk with intra-articular osteotomy;
therefore, the surgeon must be careful to minimize the soft-tissue dissection
around the articular components. When choosing internal fixation, the
surgeon must take into consideration the limited size of the components and
the quality of the bone.
When the patient presents with a malunion associated with pain
and disability six months or more after the injury, a salvage procedure
such as an arthrodesis or arthroplasty should be considered. The
type of salvage procedure depends on the patient’s functional requirements,
hand dominance, level of pain, age, and occupation.
A proximal row carpectomy should be considered only if the degenerative changes
are localized solely to the radial side of the radiocarpal joint.
The articular cartilage of the lunate and capitate must be relatively
normal. This is not usually the situation in a patient with degenerative
arthritis of the wrist due to an intra-articular fracture.
Limited arthrodesis of the radiocarpal joint (radioscapholunate
fusion) is a good alternative for a patient with localized degenerative
changes in the wrist. The outcome of this procedure depends upon
the anatomical and functional integrity of the midcarpal joint, with
a satisfactory result requiring a preserved midcarpal joint and
no carpal collapse or fixed midcarpal instability. To perform the
procedure, a longitudinal incision is made from the middle metacarpal
to 6 cm proximal to the wrist. The wrist is exposed between the third
and fourth compartments, and a dorsal transverse capsulotomy is
performed. (The posterior interosseous nerve is identified, and
its distal 3 to 4 cm is resected.) The articular cartilage from
the scaphoid, lunate, and distal part of the radius is removed.
Wrist flexion facilitates exposure. The exposed bone of the scaphoid
and lunate is held against the radius. Cancellous bone, obtained
from either the distal part of the radius or the iliac crest, is
used to fill the intercarpal space. The fusion site is fixed with
Kirschner wires, screws, or a dorsal plate with the distal screws
placed in the scaphoid and lunate.
A malunited distal radial fracture is commonly associated with
residual derangement of the distal radioulnar joint2. The three conditions responsible
for wrist pain associated with limited forearm rotation are incongruity,
impaction, and instability of the distal radioulnar joint. These
may present in isolation or in combination. Other, less frequent causes
of wrist pain are a painful nonunion of the ulnar styloid process
not associated with instability of the distal radioulnar joint,
palmar capsular contracture of the joint with loss of active supination,
radioulnar impingement after resection of the distal part of the ulna6, or an unstable distal ulnar stump
after a Sauvé-Kapandji procedure50.
Incongruity of the distal radioulnar joint may be due to extra-articular deformity
of the radius or ulna leading to abnormal orientation of the joint
surfaces, intra-articular disruption of the joint surfaces by the
fracture, or a combination of extra-articular and intra-articular
factors. Incongruity produces cartilage overload with degenerative joint
changes, painful limitation of forearm rotation, and loss of grip strength.
Ulnocarpal impaction (ulnocarpal abutment syndrome) is abnormal
contact between the ulnar head and the carpus. This occurs as a
result of radial shortening. Impaction of the ulnar head against the
carpus produces attenuation and degenerative tears of the triangular fibrocartilage
complex; chondromalacia of the ulnar head, lunate, or triquetrum;
attenuation and tears of the triquetrolunate ligament; and, finally, ulnocarpal
osteoarthritis.
Instability is due to loss of ligament support after rupture
or avulsion of the triangular ligament. Damage to secondary joint
stabilizers (the capsular ligaments, the sheath of the extensor
carpi ulnaris, the interosseous membrane, and the pronator quadratus)
or extra-articular and intra-articular osseous disruption of the
joint surface may increase the degree of laxity.
Careful clinical assessment of the joint is necessary to localize
the source of ulna-sided pain. Specifically, the examiner should
try to localize the tenderness, swelling, and crepitation to the joint,
the ulnar styloid process, the extensor carpi ulnaris sheath, or
the lunotriquetral joint. Next, the examiner should determine if
pain increases with forced supination, pronation, or ulnar deviation
or with transverse compression of the joint. The stability and the direction
of subluxation of the ulnar head (dorsal, palmar, or combined) should
be assessed, and the effect of forearm rotation on the position
of the ulnar head should be determined. Finally, active and passive
forearm rotation, wrist motion, and grip strength should be measured.
Injection of a local anesthetic may help to localize the specific
site of pain.
Standardized anteroposterior and lateral radiographs of both
wrists are helpful in the evaluation of radial deformity, subluxation,
ulnar variance, and cartilage width in the frontal plane. Ulnar
variance increases with pronation and grip and decreases with supination
and no grip. Dynamic radioulnar impingement after total or partial
resection of the ulnar head can be clearly demonstrated on a lateral
radiograph of the distal part of the forearm and the wrist made
while the patient holds a weight of 2.5 lb (1.1 kg). Abnormal contact
between the radius and the ulna can be seen on these radiographs.
Superimposing transverse slices of a computerized tomography scan
at the level of Lister’s tubercle and the bicipital tuberosity
allows assessment of rotational deformity of the distal part of
the radius. Furthermore, the computerized tomography scan is useful
for the detection of step-offs, degenerative changes, and subluxation
of the distal radioulnar joint. Computerized tomography arthrography
and/or magnetic resonance imaging may be indicated occasionally
for suspected soft-tissue and cartilage damage of the triangular
fibrocartilage complex, damage to the intercarpal ligaments, synovitis, ganglions,
and tendon lesions. Arthroscopy of the wrist remains, however, the ideal
method for evaluation and treatment of lesions of the triangular
fibrocartilage complex.
Our preferred treatment options for disorders of the distal radioulnar
joint after a radial fracture are summarized in Table II. Extra-articular
incongruity of the distal radioulnar joint is managed by restoration
of radial anatomy and reorientation of the sigmoid notch to the
ulnar head with a radial osteotomy. After the osteotomy, if the
distal radioulnar joint is stable, full passive pronation and supination
are possible, and the normal anatomic relationship between the sigmoid
notch and the ulnar head has been restored, no additional surgery
is necessary. When intra-articular incongruity of the distal radioulnar
joint is seen on plain radiographs or computerized tomography scans,
a resection arthroplasty, a Sauvé-Kapandji procedure, or
a prosthetic replacement is indicated depending on the severity
of the degenerative changes and the patient’s age, hand
dominance, and occupation. Currently, we reserve partial resection
of the ulnar head (a Bowers hemiresection interpositional technique1) for patients who make low demands on
the wrist. To prevent ulnar convergence or radioulnar impingement,
both the pronator quadratus and a "rolled anchovy" consisting
of a distally based strip of the extensor carpi ulnaris tendon are
used as interpositional material (Fig. 9). Both interposed structures are
sutured to the proximal edges of the triangular fibrocartilage complex.
Partial ulnar resection does not alter the ulnar variance, and therefore
an additional ulnar shortening either at the styloid level or at
the ulnar shaft should be done with this procedure to prevent impingement of
the ulnar styloid process on the carpus.
We have had very satisfactory results with the Bowers hemiresection
interpositional technique combined with radial osteotomy in patients
with posttraumatic deformity associated with degenerative changes
at the distal radioulnar joint1.
We reviewed our experience with this procedure in fifteen patients
who had radiographically evident degenerative changes, predominantly
ulna-sided pain, and limited rotation of the forearm31. At an average of three years, thirteen patients
were free of pain but two had some pain at the extremes of forearm rotation.
All fifteen distal radioulnar joints were stable, the average grip strength
had increased by 30%, and the outcome was very good in
four patients, good in eight, and fair in three.
In elderly patients, total resection of the ulnar head (the Darrach
procedure)6,51 still has a place
in the treatment of derangement or osteoarthritis of the distal
radioulnar joint. In this age-group, the disadvantages of this operation (reduction
of grip strength and potential instability of the ulnar stump) are remarkably
well tolerated. The most important technical details are (1) the resection
is not extended higher than the level of the ulnar neck, and (2)
the sheath of the extensor carpi ulnaris tendon is closed carefully
to prevent dorsal subluxation. Breen and one of us (J.B.J.) suggested
that, when the ulnar head is subluxated before the operation, a
primary tenodesis of the ulnar stump after head resection should
be done with distally based tendon strips of the flexor carpi ulnaris
and extensor carpi ulnaris52.
The Sauvé-Kapandji procedure (fusion of the distal radioulnar
joint with creation of a proximal ulnar pseudarthrosis)50 is recommended for younger patients who
make high functional demands on the wrist and forearm. Specific
clinical and radiographic indications for a Sauvé-Kapandji
procedure are posttraumatic osteoarthritis of the joint, chronic irreducible
dislocation of the ulnar head with extensive limitation of forearm rotation,
posttraumatic synostosis of the distal part of the forearm, simultaneous arthritic
or posttraumatic destruction of the sigmoid notch and lunate fossa,
and the need for salvage after a failed hemiresection arthroplasty53.
The two most difficult complications of the Sauvé-Kapandji
procedure are reossification of the pseudarthrosis site in the ulna
and instability of the proximal ulnar stump. To prevent the latter complication,
we use an additional palmar tenodesis with a distally based tendon
strip of the flexor carpi ulnaris to stabilize the proximal stump31. We do this because of the difficulty
of obtaining adequate stability with pronator quadratus interposition
alone. In addition, two screws are used for fixation (Fig. 10). We believe
that ectopic bone formation is reduced by careful periosteal resection,
the elimination of "sawdust," and soft-tissue
interposition of the flexor carpi ulnaris and pronator quadratus.
This operation preserves the triangular fibrocartilage complex,
the ulnocarpal ligaments, and the osseous support of the ulnar side
of the carpus, which perhaps explains why there frequently is, together
with the pain relief offered by the arthrodesis, a satisfactory increase
in grip strength. A stable and painless nonunion of the distal part
of the ulna reliably restores forearm rotation. Although some degree
of passive instability of the distal stump may be detected on clinical
examination, it usually disappears during forceful grip. We believe
that active contraction of both the extensor and the flexor carpi
ulnaris muscles may be responsible for additional dynamic stabilization
of the distal ulnar stump during active use of the hand.
Our modification of the Sauvé-Kapandji procedure with
a flexor carpi ulnaris tenodesis was evaluated in eighteen patients
who had posttraumatic derangement of the distal radioulnar joint
after a distal radial fracture53.
All patients had painful limitation of forearm rotation. After an
average duration of follow-up of five years, the average forearm
supination improved from 16° preoperatively to 77° postoperatively
and the average forearm pronation improved from 42° to 81°. Pain relief
was satisfactory, and the average grip strength improved from 36% of
the strength on the unaffected side preoperatively to 72% of
the strength on the unaffected side postoperatively.
A more recent option that obviates the disadvantages of distal
ulnar resection is prosthetic replacement of the ulnar head, as
proposed by Herbert54 (Fig. 11). After a distal radial fracture,
the aim of ulnar head replacement is to restore pain-free forearm
rotation while maintaining ulnar support to the carpus. The prerequisites
for ulnar head replacement after a fracture with incongruity of
the distal radioulnar joint are a normally oriented sigmoid notch
and adequate soft-tissue coverage. Therefore, if there is a metaphyseal
deformity, a radial osteotomy should be done to reorient the sigmoid
notch in the frontal and sagittal planes so that the radius can rotate
freely around the prosthetic head (Figs. 12-A, 12-B, and 12-C).
Through a dorsal approach, an ulna-based capsuloretinacular flap
is made. This allows access to the distal part of the ulna and the
triangular fibrocartilage complex and will be used to accomplish
a stable soft-tissue repair. The apex of the flap lies in the bed
of the extensor digiti minimi tendon, where the joint capsule attaches
to the rim of the sigmoid fossa. The extensor retinaculum (containing
the extensor carpi ulnaris tendon) is raised in a single layer with
the joint capsule and is freed from the dorsal surface of the triangular
fibrocartilage complex and from its osseous attachments to the ulna.
The triangular fibrocartilage complex is inspected and is repaired
if necessary. Templates are used preoperatively to determine the
level of the osteotomy. After the osteotomy and reaming of the ulnar
shaft, a trial prosthesis is used to establish the correct size
of the head and stem. Fluoroscopy can be employed to make a final
selection of the prosthesis. The flap is then sutured back onto
the triangular fibrocartilage complex and is advanced over the prosthesis
and reattached to the dorsal rim of the sigmoid fossa. Transosseous
nonabsorbable sutures are placed, under sufficient tension to ensure
adequate stability.
A removable above-the-elbow splint is used to prevent forearm
rotation for the first two weeks. Active motion and physiotherapy
are started ten days to two weeks after the surgery. A removable
ulnar-gutter or sugar-tong splint, allowing 30° of pronation and
supination, is used to protect the repair from undue stress during
the healing period. The splint is discarded six weeks after the
surgery, and the patient is allowed to gradually return to normal
activities. The head of the prosthesis maintains transverse radioulnar
load transmission. This prevents radioulnar convergence and restores
the interosseous space between the radius and ulna.
The prosthesis has gained popularity for the treatment of patients
with painful radioulnar impingement after a partial or total resection
of the ulnar head. This condition is often seen in association with
an unstable distal ulnar stump after a distal ulnar resection (a
Darrach procedure) or a Sauvé-Kapandji procedure. The patient
complains of a painful "click" or "catching" sensation
during forceful forearm rotation or when lifting objects. Removal
of the ulnar head (the keystone of the distal radioulnar joint)
allows the radius to fall toward the ulna when objects are lifted
with the forearm in neutral rotation (Fig. 13). The insertion of a prosthesis
that will remain stable is more difficult in these patients than
it is in patients who have not been operated upon previously. Soft-tissue
stabilization of the prosthesis is critical. Creation of an "annular" ligament
with a free tendon graft passed around the neck of the prosthesis
and fixed palmarly and dorsally to the sigmoid notch is recommended.
Since 1995, this prosthesis has been used in an international
multicenter prospective trial54.
Twenty-three patients (eleven men and twelve women) with chronic
painful instability after a previous ulnar head resection have been
operated upon. The average age was forty-five years (range, twenty-two
to sixty-five years). Previous operations included ten Darrach-type
resections, eleven Bowers-type hemiresections, and two failed silicone ulnar
head replacements; each patient had an average of three procedures (range,
one to twelve procedures). At twenty-seven months, stability and
a marked decrease in symptoms had been achieved in twenty-two patients.
One prosthesis was removed because of a low-grade infection. Use
of a prosthesis is contraindicated when the distal part of the ulna
is severely unstable and the quality of the soft tissues is poor.
With this scenario, the two possible solutions are the use of a
constrained total distal radioulnar joint prosthesis or a radioulnar
arthrodesis (a one-bone-forearm operation). Fusion of the distal
part of the ulna to the radius in a midpronation position controls
pain and instability at the expense of the loss of forearm rotation.
Malposition of the sigmoid notch in the sagittal plane aggravates
the condition because it creates incongruity of the joint surfaces
(relative subluxation of the ulnar head). Rotational deformity of the
radius plays an additional role in the etiology of instability of
the distal radioulnar joint and should be kept in mind during surgical
reconstruction. This is especially important for fractures that are
malunited with volar and pronational displacement of the distal
fragment (Smith deformity).
The most important preoperative symptom in twenty-five patients
treated with osteotomy for a malunited Smith fracture was limitation
of supination associated with dorsal subluxation of the distal part
of the ulna and pain in the distal radioulnar joint28. Radial osteotomy alone was sufficient in
eighteen patients, whereas seven required an additional partial
resection of the ulnar head to treat degenerative changes of the
joint. At an average of five years after surgery, the average supination
had improved from 44° preoperatively to 69° postoperatively and the
average extension had improved from 25° preoperatively to 55° postoperatively.
The functional outcome was rated as very good in ten patients, good in
eight, fair in three, and poor in four.
A combined procedure is usually required when there is both an
osseous deformity and deficiency of the triangular fibrocartilage
complex. Arthroscopy is used to assess the triangular fibrocartilage
complex. A peripheral or radial transosseous reattachment of the
triangular fibrocartilage complex is performed depending on the
site of the old tear. If deficiency of the triangular fibrocartilage
complex is associated with a nonunion of the ulnar styloid process,
proximal osseous reattachment is preferred. In most instances, we
add an extra-articular capsulodesis after reconstruction of the
triangular fibrocartilage complex. An ulna-based dorsal retinacular
flap is made to the level of the sixth compartment. The sheath of the
extensor carpi ulnaris tendon is not opened. Traction is applied
to the flap, which is securely fixed with transosseous sutures to
the dorsal edge of the sigmoid notch together with the dorsal aspect
of the distal radioulnar joint capsule. The extensor digiti quinti
tendon is left on top of the flap. This retinacular flap, modified
from that described by Stanley and Herbert55,
relocates the commonly ulnarly subluxated extensor carpi ulnaris
tendon on top of the ulnar head and provides additional fibrous
augmentation to the lax dorsal aspect of the capsule (Fig. 14).
Finally, if instability is associated with an ulnar-plus variance,
a shortening osteotomy should be added to the procedure. Radial
deformity, when present, is first corrected to provide an appropriate
position of the sigmoid notch and the ulnar head.
Ulnocarpal abutment is managed by restoring the radioulnar length
discrepancy to a physiological ulnar variance, as dictated by the
study of the radiographs of the patient’s unaffected wrist. Prerequisites
for a shortening osteotomy of the ulna are a well-oriented sigmoid
notch in both the frontal and the sagittal plane and no intra-articular step-offs
or degenerative changes as demonstrated by computerized tomography
scans.
The morphology of the sigmoid notch should be carefully assessed
and classified according the system described by Tolat et al.56 (Fig. 15). A type-I distal radioulnar joint
has a sigmoid notch and ulnar seat angle roughly parallel to each
other and to the long axis of the ulna, type II has a joint surface
that is oblique and pointing toward the distal part of the ulna,
and type III has a reverse oblique orientation. If a type-III sigmoid
notch is present, ulnar shortening will produce joint incongruity
with impingement of the ulnar head on the proximal edge of the notch.
In this situation, reorientation of the sigmoid notch with a radial osteotomy
is recommended (Figs. 16-A, 16-B, 16-C, and 16-D).
Ulnar shortening decompresses the ulnar compartment of the wrist,
reestablishes distal radioulnar joint congruency, and tightens both
the ulnocarpal ligaments and the triangular fibrocartilage complex,
helping to stabilize the distal part of the ulna57.
For ulnocarpal abutment with £3 mm of ulnar-plus variance
and no instability, a wafer arthroscopic resection of the distal
end of the ulnar head is an alternative, minimally invasive procedure58. In cases in which radial shortening exceeds
10 mm, ulnar shortening combined with radial lengthening and angular
correction may become necessary. Bone distraction techniques combined with
epiphysiodesis of the distal part of the ulna is an option in children26.
Symptomatic or painful nonunion of the ulnar styloid process
without instability of the distal radioulnar joint is an infrequent
problem. Usually fibrous unions of the tip of the ulnar styloid process
are extracapsular and do not produce symptoms. When a patient with
pain on the ulnar side of the wrist has an ununited ulnar styloid
process, instability and incongruity of the joint should be suspected.
If a local anesthetic block over the tender area relieves all symptoms,
a surgical excision of the styloid process without damaging the
triangular fibrocartilage complex is recommended59.
After a fracture of the distal part of the radius, contracture
of the distal radioulnar joint capsule may be responsible for limitation
of forearm rotation, especially supination. Passive stretching of the
joint is recommended after joint incongruity, subluxation, radioulnar synchondrosis,
contracture of the interosseous membrane, and derangement of the
proximal radioulnar joint have been excluded. Surgical release of the
distal radioulnar joint capsule may be necessary if nonoperative
treatment fails. The volar aspect of the joint is exposed through
a longitudinal incision just ulnar to the flexor carpi ulnaris tendon.
The dorsal cutaneous branch of the ulnar nerve is protected and
the flexor carpi ulnaris tendon and the ulnar neurovascular bundle
are retracted radially. The pronator quadratus is sectioned longitudinally
5 mm radial to its ulnar insertion. A longitudinal capsulotomy proximal
to the volar edge of the triangular fibrocartilage complex, close
to the sigmoid notch, is performed and is continued proximal to
the neck of the ulna. Passive supination is then tested. If capsular
section does not restore full supination, a total palmar capsulectomy
is performed60. After surgery,
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passive and active supination can be begun. Dynamic supination splinting may
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