MANAGEMENT OF DISTAL RADIUS MALUNION BY
CORRECTIVE OSTEOTOMY AND BONE GRAFTING
WITH DEFINITIVE FIXATION
By
Dr kishore vemula
Final year postgraduate
Department of orthopaedics
SVRRGGH.
Case 1
Case 2 case 3
Intra op
Post op
Post op protocols
• All patients are immobilised for 2 weeks for
soft tissues to heal
• After suture removal advised mobilisation
• No wt bearing and strenous activities upto
radiological healing
• Regular follow ups
MANAGEMENT OF DISTAL RADIUS MALUNION
BY CORRECTIVE OSTEOTOMY AND BONE
GRAFTING WITH DEFINITIVE FIXATION
Introduction
• Despite improvements in treatment since
early 1980’s malunion remains a common
cause of residual disability in distal radius
fractures
• “Wrist will enjoy perfect freedom in all its
motions and can be completely exempt from
pain’” colles observation in 1814
• Malunion can be caused by failure to achieve
or maintain accurate reduction or by
inadequate duration or type of
immobilisation.
• Rduction is difficult in communition,
osteoporosis
• Old age is commonly assosciated with
malunions
Malunion - deformities
• Extraarticular -Decrease in
• Radial length
• Decrease in radial
inclination
• Loss of normal volar
tilt
• Intraarticlar - articular step
≥2mm
• DRUJ incongruency or instability. -
Step of 1-2mm at distal radioulnar joint
or combination of these can occur
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
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.
Clinical features
• Excessive dorsal tilt can cause median nerve
compression
• Long term- attritional rupture of EPL tendon
Predictors of poor outcomes
fernandez et al
• Distal radius articular step of ≥2mm
• DRUJ step of 1-2mm
• Doral tilt morethan 15-20
• Volar tilt of morethan 20
• Radial length of lessthan 6mm
• Radial inclination of lessthan 10
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
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
GRAHAMS CRITERIA FOR RADIOLOGICAL
ACCEPTABLE DISTAL RADIUS MALUNION
• Radial length- shortening of < 5mm
• Radial inclination- >15
• Radial tilt – dorsal < 15
Volar < 20
• Articular incongruency – step of < 2mm at
radiocarpal joint
INDICATIONS
• All symptomatic malunions
• 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
contraindications
• active CRPS
• osteopenia
• advanced radiocarpal arthrits
• poor soft tissue coverage
• acceptable function despite deformity
STRATEGIES OF TREATMENT OF DISTAL
RADIUS MALUNION
• 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
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
• [Link] FIXATION WITH micronail
• 4. EXTERNAL FIXATION
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)
Fernandez osteotomy
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)
Shea osteotomy
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.
Proceedures to correct DRUJ
incongruency
• DRUJ preservation surgeries;
Ulnar shortening osteotomy
• DRUJ ablation sugeries;
[Link]’s pcedure
[Link] arthroplasty- partial
resection of distal ulna
[Link]- kapandji Proceedure - druj
fusion + prox ulnarpsseudoarhosis
•Thank u…..
Every one…
