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Malunions of the Distal Radius


Sameer J. Lodha, MD Robert W. Wysocki, MD Mark S. Cohen, MD

Fractures of the dista radius are common in!uries, com"risin# a""ro$imate y %& to 1'& of fractures seen in the emer#ency de"artment.1() *hese in!uries ar#e y occur in 2 distinct "o"u+ ations, a sma er subset com"osed of hi#h+ener#y fractures, -hich are often seen in youn# adu ts, and a ar#er #rou" of o-+ener#y fra#i ity fractures, -hich are more fre.uent y noted in o der adu ts. *he o/era incidence of the in!ury is e$"ected to increase o/er the ne$t 20 years, "ara e in# the a#in# of the 1S "o"u ation as a -ho e.2(3,' *reatment "aradi#ms for dista radius fractures ha/e e/o /ed si#nificant y as the biomechanics of the -rist ha/e been e ucidated. 4 thou#h initia descri"tions c assified dista radius fractures as a ar#e y homo#enous #rou" of in!uries that hea ed -e -ith minima treatment, it is noreco#ni5ed that these in!uries dis" ay si#nificant /ariation in fracture "attern and stabi ity, -ith certain fracture deformities eadin# to "oor "ro#nosis if eft uncorrected.2,% Considerab e effort has been e$"ended in in/esti#atin# and determinin# a""ro"riate treat+ ments for different fracture ty"es, takin# into account "atient+ s"ecific factors inc udin# functiona demands and o/era hea th. 6n s"ite of si#nificant ad/ances in de/e o"in# treatment strate#ies, com" ication rates from im"ro"er or fai ed treat+ ment re#imens remain hi#h, ran#in# from 2)& to )1&.7,10 Ma union is the most common com" ication fo o-in# dista radius fractures. *his occurs in a""ro$imate y 2)& of nonsur#ica y treated in!uries and a""ro$imate y 11& of o"erati/e y treated fractures.2,11,12 Ma unions may be e$tra+ articu ar 8in/o /in# the meta"hysea re#ion9 or intra+ articu ar 8manifestin# -ith residua !oint incon#ruity9 and can "resent a on# a s"ectrum of se/erity, ran#in# from asym"tomatic ra+ dio#ra"hic abnorma ities to disab in# deformities associated -ith si#nificant "ain and functiona im"airment. *he inci+ dence of c inica y a""arent ma unions -i ike y increase in the future, ref ectin# both the o/era increase in dista radius fractures and the increased functiona demands of a on#er+ i/in# adu t "o"u ation.1)(1: ;istorica y, treatment for c inica y si#nificant ma union has been o"erati/e, consistin# "rimari y of correcti/e osteoto+ mies -ith ad!unct bone #raftin# and fi$ation. Recent research to define o"tima treatment "rotoco s for ma unions has

focused on, 819 determinin# the a""ro"riate indications for inter/ention< 829 de/e o"in# a""ro"riate sur#ica techni.ues incor"oratin# ne- insi#hts into the biomechanics of -rist function< and 8)9 de/e o"in# ne- techno o#ies to im"ro/e the accuracy and efficacy of o"erati/e inter/ention. 6n this cha"ter -e -i attem"t to "ro/ide a summary of the current iterature re#ardin# dista radius ma unions -hi e detai in# some of the -ork that has #one into addressin# the .uestions isted abo/e.

Anato my
*he norma functiona anatomy of the dista radius is -e + described. *he articu ar surface is di/ided by a on#itudi+ na , sa#itta rid#e into 2 facets for the sca"hoid and unate res"ecti/e y. 4 third key articu ation, the dista radiou nar !oint 8DR1J9, is com"osed of the dista u na and the si#moid notch on the u nar surface of the dista radius. *his is the anatomic ocation of forearm rotation, a o-in# the radius and the car"us to rotate around the u na. Four radio#ra"hic measures -ith -e +estab ished norma /a ues are common y used to describe the anatomy of the dista radius and are es+ sentia for accurate y e/a uatin# ma unions. *he dista radius ty"ica y demonstrates a "a mar inc ination of a""ro$imate y 11= to 12=, a radia inc ination of 22= to 2)=, a radia en#th of 11 to 12 mm, and an u nar /ariance of >1 mm on a neutra rotation "osterior+anterior 8?49 radio#ra"h. 1 nar /ariance differs #reat y amon# indi/idua s and shou d be e/a uated by com"arison to the contra atera , unin!ured e$tremity. *he ma#nitude of acce"tab e "ostin!ury de/iation from these nor+ ma "arameters has a so been estab ished. Most authors a#ree that "a mar inc ination bet-een 1:= dorsa to 20= /o ar, radia ti t @1:=, radia en#th bet-een ' to 1: mm, and u nar /ari+ ance A) mm from the contra atera side are com"atib e -ith acce"tab e a i#nment.1,1:,13 Deformity beyond the imits defined abo/e corre ates -ith si#nificant a terations in the norma biomechanics of the -rist, -ith associated c inica manifestations. 6n the nor+ ma -rist, a""ro$imate y %2& of the a$ia oad is distributed onto the radius -ith the remainin# 1%& borne by the dista

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u na throu#h the trian#u ar fibrocarti a#e com" e$. With 2.:+mm radia shortenin#, this re ationshi" chan#es so that the u na bears 22& of the a$ia oad. Continued shorten+ in# further increases u nar oad bearin# and can resu t in sym"toms of u nocar"a abutment. Radia shortenin# has further de eterious effects in that it a ters the con#ruency of the DR1J and increases tension on the trian#u ar fibrocarti+ a#e com" e$< these chan#es can resu t in increased "ain and decreased rotation at the DR1J, -ith near y :0& oss in "ronation and a""ro$imate y )0& oss in su"ination -ith 10+mm shortenin#.1'(21 Dorsa an#u ation has simi ar effects on force distribution by shiftin# the ocus of a$ia oad bearin# from /o ar+radia to dorsa +u nar. 4t 20E dorsa an#u ation, the oad seen by the u na increases to :0& of the tota < at 2:E an#u ation this increases to 3'& of the tota oad. Dorsa an#u ation a so

affects DR1J mechanics by a terin# the con#ruity of this !oint, increasin# the ike ihood of ran#e of motion deficits in fore+ arm rotation and sym"tomatic instabi ity. Car"a biome+ chanics are affected as -e , -ith "atients de/e o"in# 1 of 2 "atterns of instabi ity. Fne subset de/e o"s dorsa radiocar"a sub u$ation -hi e maintainin# midcar"a anatomy< a se"arate subset tends to "ro#ress to an ada"ti/e dorsa interca ated se#+ ment instabi ity 8D6S69 deformity, -ith a f e$ion deformity de/e o"in# at the midcar"a !oint in an effort to com"ensate. G/idence su##ests that the atter subset is more fre.uent y sym"tomatic.22 Hoth deformity ty"es tend to ead to deficits in -rist f e$ion and forearm su"ination. Dorsa an#u ation ma union can a so cause an unsi#ht y deformity 8Fi#. 149. Bo ar an#u ation deformities, common y seen as a "roduct of SmithIs fractures, -i often resu t in deficits in e$tension and forearm rotation.2)(2:

Figure 1: A) C inica "hoto#ra"h of dorsa y+an#u ated ma union fo o-in# dista radius fracture. B) ?reo"erati/e

tem" ate for desi#n of osteotomy. C) *em" ate i ustratin# ma#nitude and direction of correction of the dista fra#ment fo o-in# osteotomy. D) ?osteroanterior and E) atera radio#ra"hs sho-in# si#nificant dorsa an#u ation, radia shortenin#, and DR1J incon#ruity. Dorsa trans ation of the car"us is a so noted.

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Malunions of the Distal Radius

Decreases in radia inc ination are another common fea+ ture of e$tra+articu ar ma unions that can interfere -ith nor+ ma -rist biomechanics. *he chan#ed "osition of the car"a tunne is hy"othesi5ed to decrease the mechanica ad/anta#e of the fin#er f e$ors, reducin# #ri" stren#th. Decreases in radiou nar de/iation are a so common y noted. Fina y, de+ creases in radia inc ination are thou#ht to be associated -ith chan#es in oad+bearin# across the -rist, -ith increased force transmitted across the unate facet of the dista radius.23 6ntra+articu ar in/o /ement is fre.uent y noted in dista radius fractures. Whi e mi d incon#ruence, as seen fo o-in# o-+ener#y fractures in o der "atients, is often -e +to erated, this is #enera y not the case in youn#er, more acti/e indi/idu+ a s. Jumerous studies ha/e found that #reater than 1 to 2 mm of residua radio#ra"hic intra+ articu ar ste"off after hea in# of dista radius fractures is associated -ith radio#ra"hic radiocar+ "a arthritis and a "oor c inica outcome, es"ecia y in youn# "atients.2'()0
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Evaluati on
6nitia e/a uation of the "atient -ith a ma union consists of a detai ed history and "hysica e$amination, -ith s"ecific em"hasis " aced on e icitin# the common findin#s of a his+ tory of "ain, -eakness, decreased ran#e of motion, instabi ity, or neuro o#ic sym"toms. *he "atientIs handedness, o/era hea th, functiona demands, and e$"ectations shou d be doc+ umented as these can stron# y affect the choice of treatment. 4ttem"ts shou d be made to oca i5e any "ain to a s"ecific anatomic ocus, es"ecia y distin#uishin# bet-een radiocar"a /ersus u nar+sided -rist "ain. ?hysica e$amination, -ith com"arison to the contra+ atera unin!ured side, shou d test #ri" stren#th, ran#e of motion in f e$ionDe$tension, "ronationDsu"ination, and ra+ dia Du nar de/iation, as -e as stabi ity at the DR1J, radio+ car"a , and midcar"a !oints. S"ecific tender "oints shou d be identified. ?articu ar attention shou d be directed to the u nar side of the -rist, e icitin# tenderness andDor si#ns of u nocar+ "a abutment. 4 neuro o#ic e$amination can he " identify features of com" e$ re#iona "ain syndrome 8CR?S9, car"a tunne syndrome, or other neuro o#ic deficits. 6nformation shou d a so be obtained re#ardin# the initia in!ury, inc udin# the mechanism and treatment. 4s "art of this e/a uation, "re+ /ious radio#ra"hs, inc udin# those of the initia in!ury, shou d be obtained and re/ie-ed if "ossib e. Further radio#ra"hic e/a uation -i be essentia . *his be+ #ins -ith a minimum of a neutra rotation ?4 and atera /ie- of each -rist. 6t is essentia to ima#e the contra atera -rist in order to obtain a base ine for com"arison. *hese radio#ra"hs -i a o- determination of the anatomic "arameters defined ear ier and .uantification of the ma#nitude and direction of the ma union. 4dditiona radio#ra"hs can be /ery usefu if further e/a uation is deemed necessary. Directin# the beam for the atera /ie20= to 2:= dista to "ro$ima -i "ermit /isua i5ation of the dista radius articu ar surface< further in+ formation re#ardin# the articu ar surface can be # eaned from ob i.ue /ie-s, -ith the "artia y su"inated ob i.ue ?4 /ie- to e/a uate the dorsa facet of the unate fossa and the "artia y "ronated /ie- to im"ro/e /isua i5ation of the radia sty oid.)1 6n cases of si#nificant articu ar surface disru"tion, or con+ siderab e rotationa deformity, " ain radio#ra"hs may not "ro/ide sufficient information. Se/era studies ha/e estab+ ished that " ain fi ms consistent y underestimate the ma#+ nitude of intra+articu ar disru"tion in dista radius fractures. 6n these cases, com"uted tomo#ra"hy 8C*9 scans, -ith sa#it+ ta , corona and )+dimensiona reconstructions can im"ro/e .uantification of the deformity and understandin# of fracture fra#ment mor"ho o#y com"ared -ith " ain fi ms.12

Treatme nt
*he #oa of treatment of a dista radius ma union is to "ro/ide a "ain+free -rist that meets the functiona demands of the

"atient. *he coro ary to this is that "atients -ith si#nificant anatomic abnorma ities, c inica y or on radio#ra"hic e$ami+ nation, may not re.uire inter/ention if they are "ain+ free and ab e to function ade.uate y #i/en their current and antici"ated functiona re.uirements. Fther re ati/e contraindications to o"erati/e inter/ention inc ude "oor o/era hea th, ad/anced "osttraumatic arthritis, se/ere osteo"orosis, com" e$ intra+ articu ar deformity, and e$istin# features of CR?S. 6n these cases, "hysica thera"y may he " achie/e soft tissue ada"ta+ tion. 6f o"erati/e treatment is -arranted, a sa /a#e "rocedure such as a "artia or tota -rist fusion may be "referred. Fn the other hand, acti/ity+ imitin# sym"toms or se/ere deformity -ith an increased risk for de#enerati/e arthritis or u nocar"a abutment in a "atient -ith e$"ected hi#h func+ tiona demands is an indication for o"erati/e treatment. 6n these situations, the #oa is to restore the norma anatomy of the -rist, or at the /ery east, restore -rist anatomy to -ithin the acce"tab e "arameters described ear ier. 6n this -ay near+norma biomechanics can be reestab ished, thereby reducin# "ain, im"ro/in# function, and diminishin# areas of abnorma articu ar stress concentration. ?ro"er "reo"erati/e " annin# is essentia in this "rocess. ? annin# be#ins by com"arin# the in!ured and unin!ured -rists, inc udin# tem" atin# 8Fi#. 1H, C9. *his -i a o"recise .uantification of the ma#nitude and direction of the deformity to he " define the fo o-in# features of the a"+ "ro"riate treatment strate#y, 819 the nature and direction of the "ro"osed osteotomy 8o"enin# /s. c osin#, /o ar /s. dor+ sa 9< 829 the need for and ty"e of bone #raft to be used< and 8)9 the re.uirement for any additiona u nar+sided "rocedures. Determination of the timin# of any "ro"osed inter/ention is a so an im"ortant "art of the " annin# "rocess. 4 thou#h some studies ha/e determined that e.ui/a ent c inica resu ts are obtained from ear y inter/ention 8A% -eeks9 and ate inter+ /ention 8@20 -eeks9, others ha/e sho-n that ear ier sur#ery is technica y easier and reduces the o/era "eriod of disabi ity. ;o-e/er, de ay may be an a""ro"riate strate#y in se ect cases of si#nificant comminution or estab ished ma union. 6n the former, de ayin# sur#ery unti some measure of conso idation has occurred may faci itate the u timate "rocedure. 6n the at+ ter, "hysica thera"y in the inter/a "rior to definiti/e treat+ ment may im"ro/e mobi ity and soft tissue ba ance.)2()2 Dorsa y an#u ated ma unions 8Fi#. 1D, G9 are ty"ica y treated -ith a dorsa o"enin# -ed#e osteotomy. *he ad/an+ ta#e of the o"enin# -ed#e osteotomy o/er the c osin# -ed#e /ariant is that it effecti/e y en#thens the radius, thereby ame+ ioratin# any radia shortenin# deformity. 4 c osin# -ed#e osteotomy, on the other hand, -i ike y accentuate a$ia shortenin#. Hy creatin# a free dista fra#ment, o"enin# -ed#e osteotomies a so "ermit mu ti" anar deformity correction, re+ storin# more norma radia and /o ar inc ination in the dista radius. *here are 2 sa ient disad/anta#es associated -ith the o"enin# -ed#e techni.ue. First, an o"enin# -ed#e osteotomy

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creates a /oid, -hich must be fi ed -ith #raft. *y"ica y, this #raft has been su"" ied by auto#enous corticocance ous or cance ous bone #raft, -ith the attendant morbidity associ+ ated -ith #raft har/est. Second y, these osteotomies re y on hea in# of the #raft construct for stabi ity. 6n the "resence of si#nificant osteo"orosis or an other-ise "oor hea in# mi ieu, there is an increased risk of nonunion or construct fai ure com"ared -ith c osin# -ed#e "rocedures. ;o-e/er, the im+ "ro/ed deformity correction afforded by o"enin# -ed#e os+ teotomies has made them the "referred sur#ica techni.ue for ma union correction.): 6n the case of dorsa y an#u ated e$tra+articu ar ma unions, osteotomy -ith " ate fi$ation -as historica y "erformed throu#h a dorsa a""roach, accessin# the dista radius bet-een the second and fourth dorsa com"artments. ;o-e/er, -ith the ad/ent of "recontoured, /o ar ockin# " ate techno o#y, sur#eons no- ha/e the abi ity to "erform the osteotomy and fi$ation /ia a /o ar a""roach. *his a""roach "ro/ides more s"ace to accommodate the " ate on the /o ar side, and the o/er yin# "ronator .uadratus forms a barrier bet-een the " ate and the f e$or tendons.)3(20 6n this techni.ue, the ;enry a""roach may be used to e$"ose the /o ar dista radius 8Fi#. 249. 4 common strate#y is to fi$ the " ate dista y first, a o-in# the sur#eon to identify the o"tima osteotomy ocation and direction 8Fi#. 2H9. 6de+ a y, the cut shou d be "ara e to the articu ar surface and at the a"e$ of the deformity. *he osteotomy is started -ith an osci atin# sa- and com" eted -ith an osteotome. *he " ate+ dista fra#ment construct is then reduced to the radia shaft, in the "rocess correctin# the deformity in the form of a dorsa o"enin# -ed#e 8Fi#. 2C(G9. 4n#u atory deformities -ithout bone oss or a$ia shortenin# can often be corrected so e y by hin#in# o"en dorsa y and radia y on the a""osed /o ar cortices< ade.uate restoration of anatomy in more com" e$ ma unions may resu t in a #a" bet-een the anterior cortices, es"ecia y -hen si#nificant en#thenin# is re.uired. F"tima

Figure 2: A) 6ntrao"erati/e "icture sho-in# /o ar e$"osure of the dista radius. *he hea ed fracture ine is c ear y /isib e.

B) *he /o ar ockin# " ate is "ro/isiona y a"" ied to the dista fra#ment. C) Fo o-in# the osteotomy, the " ate -as rea"" ied to the dista fra#ment, and the " ate+fra#ment construct reduced to the "ro$ima shaft. D) Bo ar ockin# " ate fo o-in# fina fi$ation. E) Latera f uorosco"ic ima#e fo o-in# " ate a"" ication. *he ne- y created dorsa defect is c ear y /isib e.

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"ositionin# of the dista fra#ment may a so be faci itated by re easin# the brachioradia is tendon, -hich acts as a short+ enin#, radia y+de/iatin# deformin# force. 4bundant dorsa ca ous and thickenin#Dscarrin# of the dorsa "eriosteum may re.uire a dorsa a""roach to #ain ade.uate mobi ity of the dista fra#ment. *he dorsa defect that is created is then fi ed -ith a""ro"riate bone #raft. *he #raft may be "acked in /ia the /o ar e$"osure< ho-e/er, a imited dorsa a""roach im"ro/es /isua i5ation 8Fi#. )9. ?osto"erati/e radio#ra"hs shou d demonstrate a #ood fi of the defect 8Fi#. 29.21(2) C osin# -ed#e osteotomies, discussed brief y abo/e, "res+ ent a tenab e a ternati/e sur#ica techni.ue in s"ecific situ+ ations. F der adu ts -ith osteo"enia ha/e a si#nificant risk of construct fai ure and oss of fi$ation -ith o"enin# -ed#e osteotomies, and may be indicated for a c osin# -ed#e "ro+ cedure, -hich does not #enera y re.uire #raft use. *his techni.ue a o-s a""ro"riate restoration of radiocar"a and midcar"a a i#nment. ;o-e/er, as mentioned, this techni.ue a so resu ts in net shortenin# of the radius, -hich may "ro+ duce or -orsen e$istin# DR1J incon#ruity. *hese "rocedures are therefore often cou" ed -ith an u nar+sided inter/ention, in the form of an u nar head resection or an u nar shortenin# osteotomy. ?erformin# the u nar "rocedure "rior to fi$ation of the radia fra#ments may increase the mobi ity of the dista radia fra#ment and im"ro/e the fina reduction.22(23 ?a mar y an#u ated ma unions are far ess common y en+ countered but may resu t from fai ed treatment of SmithIs fractures. 6n these ma unions, the dista fra#ment is often f e$ed, "ronated, and shortened. *he o"erati/e techni.ue is simi ar to that detai ed abo/e for dorsa y an#u ated ma unions. 4 /o ar a""roach is used, and an o"enin# -ed#e osteotomy "erformed. *he dista fra#ment is ty"ica y then e$tended and su"inated to correct the deformity. Hone #raft is " aced in the "a mar #a", and a /o ar " ate is a"" ied for fi$ation. Correct+ in# the deformity in this fashion si#nificant y im"ro/es #ri" stren#th and forearm ran#e of motion. *he sur#ica treatment of intra+articu ar ma union is frau#ht -ith cha en#es, inc udin# difficu ty in /isua i5in# the articu ar surface, findin# and de/e o"in# the fracture ines, and im"airin# the /ascu ar su"" y to fracture fra#ments. Re ati/e y narro- indications for this "rocedure e$ist< it shou d not be attem"ted in the "resence of si#nificant intra+ articu ar

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or fine osci atin# sa-, fibrocarti a#e and ca us are resected to e$"ose the true articu ar ed#es, and the articu ar fra#ments are rea""ro$imated and fi$ed usin# K+-ires, scre-s, " ates, or a combination of these 8Fi#. :9. 4ny remainin# bony defects are fi ed -ith bone #raft. *he a""roach used can /ary, but #ener+ a y aims to e$"ose the side -ith the #reatest deformity. Dorsa a""roaches "ermit direct /isua i5ation of the articu ar surface /ia a ca"su otomy< in /o ar a""roaches, -here the radiocar"a i#aments are eft intact, the surface is obser/ed throu#h the fracture. 6ntra+o"erati/e f uorosco"y is essentia for additiona e/a uation. Re"orted resu ts -ith these "rocedures indicate fa+ /orab e outcomes in e$"erienced hands.27 Rin# et a . re"orted on a series of 2) "atients and described sym"tomatic and functiona im"ro/ement fo o-in# intra+articu ar osteotomy, a thou#h they noted that norma -rist anatomy and function are on y rare y restored.:0 Whether ater de/e o"ment of ar+ throsis is a/oided remains to be seen.27 1 nar+sided inter/entions, mentioned brief y abo/e, may be re.uired in some instances. 6n se ect ma union cases -here

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Figure 2: 8Continued 9 comminution, e$istin# arthrosis, se/ere osteo"orosis, or in "atients -ith o- functiona demands. 6n these cases, non+ sur#ica treatment and future sa /a#e "rocedures may be bet+ ter o"tions. Fsteotomy is best reser/ed for sim" e de"ressed die+"unch fra#ments, es"ecia y of the /o ar unate facet.2',2% Fe- "ub ished re"orts e$ist on the o"tima sur#ica tech+ ni.ues for intra+articu ar osteotomies. 6n #enera , these de+ scribe simi ar o/era strate#ies in that the ori#ina fracture ines are recreated as "recise y as "ossib e -ith an osteotome
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Figure : A) Limited dorsa a""roach e$"osin# the dorsa defect. B) Cance ous auto#enous #raft obtained from the i"si atera o ecranon "rocess. C) Hone #raft "acked into the dorsa defect.

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Figure : 8Continued 9

an iso ated radia a$ia shortenin# deformity is "resent -ith no concomitant radia or /o ar inc ination abnorma ity, an u nar+ sided "rocedure a one 8e#, an u nar shortenin# osteotomy9 may ade.uate y address the "atho o#y by restorin# norma u nar /ariance. DR1J dysfunction in the form of incon#ruity or instabi ity may a so necessitate an u nar+sided inter/ention, "ro/ided it is not sim" y secondary to e$tra+articu ar ma union of the radius. Se/era "rocedures ha/e been "ro"osed to treat this dysfunction. *he Darrach "rocedure may be a""ro"riate for marked increased u nar /ariance and u nocar"a abutment in o der "atients -ith imited functiona demands, in -hom the decreased #ri" stren#th often seen as a resu t of the "roce+ dure is -e + to erated. *he Sau/L+Ka"and!i techni.ue, on the other hand, may be more a""ro"riate for youn#er "atients, a thou#h "ersistent "ain fo o-in# this "rocedure has been re"orted and it is more technica y demandin#.:1

!raft Choi"es
4 number of #raft choices ha/e been "ro"osed to address the #a" created by o"enin# -ed#e osteotomies. ?rior to the

ad/ent of fi$ed+an# e " atin# constructs, structura cortico+ cance ous bone #raft, obtained most common y from the i iac crest had been "referred. *hese #rafts "ossessed the ca+ "acity to bear oad, -hich "ro/ided considerab e stabi ity to the o/era construct, a beit at the cost of often si#nificant donor site morbidity and "ossib e si5e mismatch bet-een the #raft and the reci"ient site. With /o ar fi$ed+an# e " atin# no- a/ai ab e, the " ate itse f "ro/ides structura su""ort, and nonstructura cance ous auto#raft can be used -ith com+ "arab e resu ts. *he #raft and can be easi y obtained from the i"si atera o ecranon -ith minima donor site morbidity 8Fi#. )H9.:2 More recent y, cance ous a o#raft and commercia y a/ai + ab e bone substitutes inc udin# ca cium "hos"hate and car+ bonated hydro$ya"atite ha/e been com"ared to auto#enous #raft in the settin# of correcti/e osteotomy -ith com"arab e hea in# rates.:)(:' 4 ternati/e substitutes a so inc ude "orous tanta um -ed#es, -hich "ro/ide an osteoconducti/e, struc+ tura y sound scaffo d for bone in#ro-th and ha/e been used e$tensi/e y in hi" and knee arthro" asty. Hone mor"ho#enic "roteins ha/e a so been studied "re iminari y in this conte$t.:%

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Malunions of the Distal Radius

Figure #: A) ?4 and B) atera "osto"erati/e radio#ra"hs sho-in# " ate "osition, correction of radia an#u ation and
shortenin#, and #ood fi of the cance ous auto#raft.

*he ad/anta#es of these substitutes inc ude decreased o"+ erati/e time and reduced donor site morbidity, a thou#h the cost of the #raftin# substitute must be considered.:7 Further study is needed before these substitutes can be une.ui/oca y recommended.

Future Dire"tions
*he treatment of dista radius ma unions continues to e/o /e as ne- techno o#ies are introduced. Whi e on#+term studies re#ardin# these techno o#ies are sti ackin#, initia re"orts su##est "romisin# resu ts. *he increasin# /ersati ity of C* scannin# -ith the a/ai + abi ity of )+dimensiona reconstructions has made com"uter+ assisted techni.ues for treatin# ma unions feasib e. 4s described by 4th-a et a ., one strate#y for usin# com"uter+ assisted techno o#y in/o /es obtainin# C* scans of both the in!ured and unin!ured u""er e$tremity. 4 com"uter "ro#ram can be used to create an osteotomy in the /irtua ma united radius and a i#n the osteotomi5ed fra#ment to the contra atera side. *he ocation of the osteotomy and the ma#nitude and direction of the correctin# dis" acement are recorded. *he sur#eon can use this com"uter mode to
4merican Society for Sur#ery of the ;and

#uide the intrao"erati/e osteotomy and a""ro"riate y "o+ sition the dista fra#ment. *he system therefore faci itates in+de"th "reo"erati/e " annin# as -e as intrao"erati/e #uidance. 6nitia re"orts ha/e sho-n #ood c inica resu ts -ith this techni.ue< -hether the resu ts are si#nificant y bet+ ter than those obtained -ith traditiona techni.ues has yet to be determined. ),30,31 4rthrosco"ica y+assisted techni.ues ha/e been described in the "rimary treatment of dista radius fractures -ith articu ar in/o /ement, -ith cited ad/anta#es inc udin# the abi ity to di+ rect y /isua i5e and reduce articu ar fra#ments and to e/a uate and "otentia y treat i#amentous "atho o#y in a ess in/asi/e fashion than traditiona o"en techni.ues. Some #rou"s ha/e at+ tem"ted to e$tend this e$"erience to the treatment of dista ra+ dius ma unions.32(32 De ?iMa et a . re"orted on 11 "atients -ith intra+articu ar ma unions treated -ith arthrosco"ica y #uided osteotomies and fi$ation -ith mean fo o-+u" of )2 months. 6n their "atients, a ste"offs -ere corrected by arthrosco"ic and radio#ra"hic e/a uation< ho-e/er, 2 of 11 "atients had residua #a"s 8A2 mm9. C inica outcomes -ere com"arab e to resu ts of o"en treatment.3: *hou#h this initia re"ort seems "romisin#, on#er studies are needed to assess the im"act on the de/e o"+ ment of ater sta#e radiocar"a arthrosis.33

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Hand Surgery Update V

A
Figure $: A) ?reo"erati/e ?4 radio#ra"h and B) C*

scan and corona reconstruction ima#e demonstrate an intra+ articu ar ma union -ith ste"off of the unate facet. C) ?osto"erati/e ?4 fi ms fo o-in# intra+articu ar osteotomy and fi$ation -ith a /o ar " ate, sho-in# correction of the intra+ articu ar ste"off.

%umma ry
*he incidence of sym"tomatic dista radius ma unions is e$+ "ected to increase o/er the ne$t 2 decades. *reatin# these deformities is cha en#in#, but shou d #enera y ead to fa/or+ ab e outcomes in the hands of sur#eons fami iar -ith -rist anatomy and biomechanics, and in the conte$t of a""ro"riate "reo"erati/e " annin#.3' ;o-e/er, reconstruction does not restore anatomy or function to that of the norma -rist, and the "re/ention of ma union throu#h a""ro"riate initia treat+ ment remains the o"tima strate#y.3%

C
Figure $:
8Continued 9

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Malunions of the Distal Radius

Referen"es
1. Jana 4D, Joshi 4, Lichtman DM. ? atin# of the dista radius. J 4m 4cad Frtho" Sur# 200:<1)8)9,1:7(1'1. 2. ?o#ue DJ, Bie#as SF, ?atterson RM, ?eterson ?D, Jenkins DK, S-eo *D, et a . Gffects of dista radius frac+ ture ma union on -rist !oint mechanics. J ;and Sur# 4m 1770<1:8:9,'21('2'. 3. 4th-a NS, G is RG, Sma CF, ?ichora DR. Com+ "uter+assisted dista radius osteotomy. J ;and Sur# 200)<2%839,7:1(7:%. 4. Cohen M, Ju"iter J. Fractures of the Dista Radius. 6n, Ske eta *rauma, Hasic Science, Mana#ement, and Recon+ struction. Gdited by Hro-ner HD, Ju"iter J, Le/ine 4M, *rafton ?N and Nreen JG, ?hi ade "hia, ?4, Saunders G se/ier< 2007. ". 120:(12:%. 5. 4 ffram ?4, Hauer NC. G"idemio o#y of fractures of the forearm. 4 biomechanica in/esti#ation of bone stren#th. J Hone Joint Sur# 4m 1732<22+4,10:(112. 6. Hen#ner 1, Johne F. 6ncreasin# incidence of forearm fractures. 4 com"arison of e"idemio o#ic "atterns 2: years a"art. 4cta Frtho" Scand 17%:<:3829,1:%(130. 7. F-en R4, Me ton LJ), Johnson K4, 6 stru" DM, Ri##s HL. 6ncidence of Co esI fracture in a Jorth 4merican community. 4m J ?ub ic ;ea th 17%2<'2839,30:(30'. 8. 4 tissimi M, 4ntenucci R, Fiacca C, Mancini NH. Lon#+ term resu ts of conser/ati/e treatment of fractures of the dista radius. C in Frtho" Re at Res 17%3< 82039,202(210. 9. ;irahara ;, Jea e ?N, Lin O*, Cooney W?, 4n KJ. Kinematic and tor.ue+re ated effects of dorsa y an#u ated dista radius fractures and the dista radia u nar !oint. J ;and Sur# 4m 200)<2%829,312(321. 10. Hushne HD, Hynum DK. Ma union of the dista radius. J 4m 4cad Frtho" Sur# 200'<1:819,2'( 20. 11. S a#e H, Luenam S, ?ichora D. Mana#ement of ?ost+ *raumatic Ma union of Fractures of the Dista Radius. Frtho" C in Jorth 4m 200'<)%829,20)(213. 12. ?rommersber#er KJ, Froehner SC, Schmitt RR, Lan5 1H. Rotationa deformity in ma united fractures of the dista radius. J ;and Sur# 4m 2002<27819,110(11:. 13. Rin# D. *reatment of the ne# ected dista radius fracture. C in Frtho" Re at Res 200:<82)19,%:(72. 14. Ladd 4L, ;uene DS. Reconstructi/e osteotomy for ma union of the dista radius. C in Frtho" Re at Res 1773<8)2'9,1:%(1'1. 15. Nraham *. Sur#ica Correction of Ma united Frac+ tures of the Dista Radius. J 4m 4cad Frtho" Sur# 177'<:8:9,2'0(2%1. 16. Nart and JJJ, Wer ey CW. G/a uation of hea ed Co esI fractures. J Hone Joint Sur# 4m 17:1<))+4829,%7:( 70'.
4merican Society for Sur#ery of the ;and

17. Hronstein 4J, *rumb e *G, *encer 4F. *he effects of dista radius fracture ma a i#nment on forearm rotation, a cada/+ eric study. J ;and Sur# 4m 177'<22829,2:%(232. 18. 4dams HD. Gffects of radia deformity on dista radiou nar !oint mechanics. J ;and Sur# 4m 177)<1%8)9,272(27%. 19. He MJ, ;i RJ, McMurtry RO. 1 nar im"in#ement syndrome. J Hone Joint Sur# Hr 17%:<3'819,123(127. 20. ;o in#s-orth R, Morris J. *he im"ortance of the u nar side of the -rist in fractures of the dista end of the radius. 6n!ury 17'3<'829,23)(233. 21. Werner FW, ?a mer 4K, Fortino MD, Short W;. Force transmission throu#h the dista u na, effect of u nar /ariance, unate fossa an#u ation, and radia and "a mar ti t of the dista radius. J ;and Sur# 4m 1772<1'8)9,22)( 22%. 22. ?ark MJ, Cooney W?), ;ahn MG, Looi K?, 4n KJ. *he effects of dorsa y an#u ated dista radius fractures on car"a kinematics. J ;and Sur# 4m 2002<2'829,22)(2)2. 23. Hickerstaff DR, He MJ. Car"a ma a i#nment in Co esI fractures. J ;and Sur# Hr 17%7<12829,1::(130. 24. Kihara ;, ?a mer 4K, Werner FW, Short W;, Fortino MD. *he effect of dorsa y an#u ated dista radius fractures on dista radiou nar !oint con#ruency and forearm rotation. J ;and Sur# 4m 1773<21819,20(2'. 25. Berhae#en F, De#reef 6, De Smet L. G/a uation of cor+ recti/e osteotomy of the ma united dista radius on mid+ car"a and radiocar"a ma a i#nment. J ;and Sur# 4m 2010<):819,:'(31. 26. Fernande5 DL, Ca"o J*, Non5a e5 G. Correcti/e osteotomy for sym"tomatic increased u nar ti t of the dista end of the radius. J ;and Sur# 4m 2001<23829,'22(')2.

27. Harat5 MG, Jardins Des J, 4nderson DD, 6mbri# ia JG. Dis" aced intra+articu ar fractures of the dista radius, the effect of fracture dis" acement on contact stresses in a cada/er mode . J ;and Sur# 4m 1773<21829,1%)(1%%. 28. 4nderson DD, Desh"ande HR, Danie *G, Harat5 MG. 4 three+dimensiona finite e ement mode of the radiocar"a !oint, dista radius fracture ste"+off and stress transfer. 6o-a Frtho" J 200:<2:,10%(11'. 29. No dfarb C4, Rud5ki JR, Cata ano LW, ;u#hes M, Horre i JJ. Fifteen+year outcome of dis" aced intra+articu ar fractures of the dista radius. J ;and Sur# 4m 2003<)1829,3))(3)7. 30. Knirk JL, Ju"iter JH. 6ntra+articu ar fractures of the dista end of the radius in youn# adu ts. J Hone Joint Sur# 4m 17%3<3%8:9,32'(3:7. 31. Smith DW, ;enry M;. *he 2: de#rees "ronated ob i.ue /ie- for /o ar fi$ed+an# e " atin# of dista radius fractures. J ;and Sur# 4m 2002<27829,'0)('03. 32. Ju"iter JH, Rin# D. 4 com"arison of ear y and ate recon+ struction of ma united fractures of the dista end of the radius. J Hone Joint Sur# 4m 1773<'%8:9,')7('2%.

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33. Fernande5 DL. Correction of "ost+traumatic -rist deformity in adu ts by osteotomy, bone+#raftin#, and interna fi$ation. J Hone Joint Sur# 4m 17%2<328%9,1132( 11'%. intra+articu ar ma union of the dista "art of the radius. Sur#ica techni.ue. J Hone Joint Sur# 2003<%% Su"" 1 ?t 2, 202(211. 49. ;sieh MK, Chen 4C, Chen# CO, Chou OC, Chan OS, ;su KO. Re"ositionin# osteotomy for intra+articu ar ma union of dista radius -ith radiocar"a andDor dista radiou nar !oint sub u$ation. J *rauma 2010<37829,21%(222. 50. Rin# D, ?rommersber#er KJ, Non5a e5 de ?ino J, Ca"o+ massi M, S u ite M, Ju"iter JH. Correcti/e osteotomy for intra+articu ar ma union of the dista "art of the radius. J Hone Joint Sur# 4m 200:<%'8'9,1:0)(1:07. 51. Naeb er C, McPueen MM. 1 nar "rocedures for "ost+ traumatic disorders of the dista radiou nar !oint. 6n!ury 200)<)2819,2'(:7. 52. Rin# D, Rober#e C, Mor#an *, Ju"iter JH. Fsteotomy for ma united fractures of the dista radius, a com"arison of structura and nonstructura auto#enous bone #rafts. J ;and Sur# 4m 2002<2'829,213(222. 53. 4bramo 4, *a#i M, Nei!er M, Ko"y o/ ?. Fsteotomy of dorsa y dis" aced ma united fractures of the dista radius, no oss of radio#ra"hic correction durin# hea in# -ith a minima y in/asi/e fi$ation techni.ue and an in!ectab e bone substitute. 4cta Frtho" 200%<'7829,232(23%. 54. Ladd 4L, ? iam JH. 1se of bone+#raft substitutes in dista radius fractures. J 4m 4cad Frtho" Sur# 1777<'8:9,2'7(270. 55. ;arti#an HJ, Cohen MS. 1se of bone #raft substitutes and bioacti/e materia s in treatment of dista radius fractures. ;and C inics 200:<218)9,227(2:2. 56. Lo5ano+Ca deron S, Moore M, Liebman M, Ju"iter JH. Dista radius osteotomy in the e der y "atient usin# an#u ar stab e im" ants and Jorian bone cement. J ;and Sur# 4m 200'<)28'9,7'3(7%). 57. Fbert L, Le"a#e D, Nasse J, Rochet S, Narbuio ?. G$tra+ articu ar dista radius ma union, *he "hos"hate cement a ternati/e. Frtho" *raumato Sur# Res. 2010 Ju . 1)< 58. Gkro 6, ;a!ducka C, Court+Hro-n C, McPueen MM. 4 com"arison of RhHM?+' 8F?+19 and auto#enous #raft for meta"hysea defects after osteotomy of the dista radius. 6n!ury 200%<)7 Su"" 2,S')(%2. 59. Ju"iter JH, Winters S, Si#man S, Lo-e C, ?a""as C, Ladd 4L, et a . Re"air of fi/e dista radius fractures -ith an in+ /esti#ationa cance ous bone cement, a "re iminary re"ort. J Frtho" *rauma 177'<11829,110(113. 60. Ju"iter JH, Ruder J, Roth D4. Com"uter+#enerated bone mode s in the " annin# of osteotomy of mu tidirectiona dista radius ma unions. J ;and Sur# 4m 1772<1'8)9,203( 21:. 61. Leon# JL, Hui!5e N4, Fu GC, Stockmans F, Ju"iter JH. Com"uter+assisted /ersus non+com"uter+assisted "reo"+ erati/e " annin# of correcti/e osteotomy for e$tra+articu ar

34. Oasuda M, Masada K, 6-akiri K, *akeuchi G. Gar y correc+ ti/e osteotomy for a ma united Co esI fracture usin# /o ar a""roach and ca cium "hos"hate bone cement, a case re"ort. J ;and Sur# 4m 2002<27839,11)7(1122. 35. Berhae#en F, De#reef 6, De Smet L. Correcti/e osteotomy of the dista radius, dorsa or /o ar a""roach, c osin# or o"enin# -ed#e. 4cta Frtho" He # 2010<'38:9,302(30'. 36. Kamano M, ;onda O, Ka5uki K, Oasuda M. ?a mar " at+ in# for dorsa y dis" aced fractures of the dista radius. C in Frtho" Re at Res 2002<8)7'9,20)(20%. 37. Frbay JL. *he treatment of unstab e dista radius fractures -ith /o ar fi$ation. ;and Sur# 2000<:829,10)( 112. 38. Frbay JL, Fernande5 DL. Bo ar fi$ation for dorsa y dis+ " aced fractures of the dista radius, a "re iminary re"ort. J ;and Sur# 4m 2002<2'829,20:(21:. 39. Frbay JL, Fernande5 DL. Bo ar fi$ed+an# e " ate fi$ation for unstab e dista radius fractures in the e der y "atient. J ;and Sur# 4m 2002<27819,73(102. 40. Smith DW, ;enry M;. Bo ar fi$ed+an# e " atin# of the dista radius. J 4m 4cad Frtho" Sur# 200:<1)819,2%()3. 41. de ?ina F, Narcia+Herna FJ, Studer 4, Re#a ado J, 4ya a ;, Ca#i#a L. Sa#itta rotationa ma unions of the dista radius, the ro e of "ure derotationa osteotomy. J ;and Sur# Gur 2007<)2829,130(13:. 42. Shea K, Fernande5 DL, Ju"iter JH, Martin CJ. Correc+ ti/e osteotomy for ma united, /o ar y dis" aced fractures of the dista end of the radius. J Hone Joint Sur# 4m 177'<'78129,1%13(1%23. 43. Watson ;K, Cast e *;J. *ra"e5oida osteotomy of the dis+ ta radius for unacce"tab e articu ar an#u ation after Co esI fracture. J ;and Sur# 4m 17%%<1)839,%)'(%2). 44. Fernande5 DL. Radia osteotomy and Ho-ers arthro" asty for ma united fractures of the dista end of the radius. J Hone Joint Sur# 4m 17%%<'08109,1:)%(1::1.

45. ?osner M4, 4mbrose L. Ma united Co esI fractures, correc+ tion -ith a bi" anar c osin# -ed#e osteotomy. J ;and Sur# 4m 1771<13839,101'(1023. 46. Wada *, 6so#ai S, Kanaya K, *sukahara *, Oamashita *. Simu taneous radia c osin# -ed#e and u nar shortenin# osteotomies for dista radius ma union. J ;and Sur# 4m 2002<27829,232(2'2. 47. Ruch DS, Wray W;), ?a"adoniko akis 4, Richard MJ, Le/ersed#e FJ, No dner RD. Correcti/e osteotomy for iso ated ma union of the "a mar unate facet in dista radius fractures. J ;and Sur# 4m 2010<):8119,1''7( 1'%3. 48. ?rommersber#er KJ, Rin# D, de ?ino JN, Ca"omassi M, S u ite M, Ju"iter JH. Correcti/e osteotomy for

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dista radius ma unions, a randomi5ed contro ed tria . HMC Muscu oske et Disord 2010<11,2%2. 62. No dfarb C4. Dista radius. F"inion, arthrosco"ica y assisted fracture fi$ation. J Frtho" *rauma 2002<1%829,2:1(2:2. 63. Lutsky K, Hoyer M6, Steffen J4, No dfarb C4. 4rthrosco"ic assessment of intra+articu ar dista radius fractures after o"en reduction and interna fi$ation from a /o ar a""roach. J ;and Sur# 4m 200%<))829,2'3(2%2. 64. ;er5ber# N. 6ntra+articu ar fracture of the dista radius, arthrosco"ic+assisted reduction. J ;and Sur# 4m 2010< ):879,1:1'(1:17. 65. de ?ina F, Ca#i#a L, Narcia+Herna FJ, Studer 4, Re#a ado J, *hams C. 4rthrosco"ica y #uided osteotomy for mana#e+ ment of intra+articu ar dista radius ma unions. J ;and Sur# 4m 2010<):8)9,)72()7'. 66. Ruch DS, Ba ee J, ?oeh in# NN, Smith H?, Ku5ma NR. 4rthrosco"ic reduction /ersus f uorosco"ic reduction in the mana#ement of intra+articu ar dista radius fractures. 4rthrosco"y 2002<208)9,22:(2)0. 67. Lo5ano+Ca deron S4, Hrou-er KM, Doornber# JJ, Nos in#s JC, K oen ?, Ju"iter JH. Lon#+term outcomes of correcti/e osteotomy for the treatment of dista radius ma union. J ;and Sur# Gur 2010<):8:9,)'0()%0. 68. F inkki a *, Raatikainen *, Kaare a F, ;ama ainen M. Correcti/e osteotomy for ma union of the dista radius. 4rch Frtho" *rauma Sur# 2000<12081+29,2)(23.

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