correction of post-traumatic wrist deformity in adults by...

Copyright 1982 by The Journal of Bone and Joint Surgery, Incorporated

Correction of Post-Traumatic Wrist Deformity in Adultsby Osteotomy, Bone-Grafting, and Internal Fixation

BY DIEGO L. FERNANDEZ, M.D.*, BERNE, SWITZERLAND

From the Department of Orthopaedic Surgery, University of Berne, Berne

ABSTRACT: A corrective osteotomy for post-traumatic malalignment of the distal end of the radiuswas performed in twenty patients who were followedfor an average of 3.6 years. The indications for correc-tion were based on age, degree of deformity, limitationof function, pain, and appearance of the wrist. Theprocedure included an opening-wedge metaphyseal os-teotomy combined with insertion of a graft and rigidinternal fixation with a plate and screws to permit earlymotion. Depending on the direction of the angulation, adorsal or volar approach was employed to guarantee abuttressing effect of the plate. The procedure gavesatisfactory results when there were no degenerativechanges in the radiocarpal or intercarpal joints andwhen the preoperative range of motion of the wrist wasadequate. The results were graded as excellent in fivepatients, good in ten, fair in four, and poor in one.

Closed treatment of Colles fractures leads to satisfac-tory clinical results in the great majority of patients. Ade-quate function of the wrist and absence of pain can be ex-pected despite radiographic evidence of a malunion andshortening of the radius as well as subluxation of the distalradio-ulnar joint. These results are mainly due to the factthat Colles fractures occur predominantly in elderly pa-tients who no longer engage in strenuous manual activitiesan~l therefore the functional requirements of the wrist aremuch reduced. Conversely, post-traumatic deformity inyounger, "active patients is less well tolerated, especially inthose engaged in heavy manual work or who require anormal ~ange of motion Of the wrist (such as musicians,technicians, and surgeons). It is mainly for this group ofpatients that-surgical correction of the malunited radiusshould be considered.

Serious deformities of the wrist can usually be pre-vented by proper treatment of the original fracture, espe-cially the unstable types with a strong tendency to redis-place in a plaster cast after adequate initial reductiona’4’6’7.

Sometimes, however, deformity does develop, and in suchpatients better function and a more normal-appearing wristcan be restored by a corrective osteotomy through the siteof the original fracture..

The deformity usually becomes symp.tomatic if theangulation of the distal articular surface of the radius ismore than 25 to 30 degrees in the sagittal or frontal plane

* Orthop~idische Klinik, Inselspital, CH-3010, Berne, Switzerland.

and when there is a significant discrepancy (six millimetersor more) between the lengths of the radius and the ulna,especially in young, manually active patients.

A shortening osteotomy of the ulna13 or a resection ofthe distal end of the utna5 does not restore the iaormalanatomy of the wrist joint or correct the pathologicallydisplaced flexion-extension arc of motion in these patients.In the elderly patient, a Darrach resection of the distal endof the ulna5 is the method of choice for the treatment ofderangement, post-traumatic or rheumatoid arthritis, andpainful subluxation of the distal radio-ulnar joint due tomalunion of a Colles fracture.

In general, radial osteotomy is rarely indicated andshould be reserved for a selected group of young patientswho need anatomical restoration of the wrist for specificfunctional requirements.

Linear osteotomy with interposition of a graft hasbeen described in the past by Campbell, Speed aridKnight, and Hohmann. Merle d’Aubign6 and Joussemet11

proposed a dome-shaped multiple-facet osteotomy to re-.,;tore length without using a graft. These techniques re-quire the use of a plaster cast to immobilize the wrist for.,;ix.. to eight weeks after operation.

It is the purpose of this paper to describe anopening-wedge metaphyseal osteotomy that combines theuse of a graft and rigid internal fixation, and allows earlyunrestricted active motion of the wrist. I am reporting on:my experience with twenty consecutive patients who had amalunion of the distal end of the radius and an averagefollow-up of 3.6 years.

Material and Methods

Between 1972 and 1980, twenty adults were treatedwith corrective osteotomy of the radius at the level of thewrist for an extra-articular post-traumatic deformity. Thir-teen patients were men and seven were women. The meanage was thirty-four years (range, twenty to sixty-fiveyears) and the average follow-up was 3.6 years (range,two to eight years).

Corrective osteotomy was considered to be indicated

in: (1) manually active patients who had a symptomaticextra-articular malunion of the distal end of the radiuscausing angulation of more than 25 to 30 degrees in eitherthe frsntal or the sagittal plane without significant de’2’

generative changes in the wrist joint (such as narrowing ofthe joint space, intra-articular incongruency, subchondralsclerosis, and osteophytic reaction), and in whom it was

1164 THE JOURNAL OF BONE AND JOINT SURGERY

CORRECTION OF POST-TRAUMATIC WRIST DEFORMITY IN ADULTS

thought that the result of either a Darrach procedure or ashortening osteotomy of the ulna would be uncertain be-cause the deformity of the radius would not be corrected,and (2) patients who wished to have the deformity cor-rected even though they had adequate function of thewrist.

Patients who had a lengthening osteotomy for short-ening of the radius after post-traumatic premature epiph-yseal fusion, as well as those who had an intra-articular os-teotomy, were not included in this series because of thedifferent therapeutic and prognostic problems in thosesituations. However, these lesions are also indications fora corrective osteotomy at the level of the wrist.

The operation was considered to be contraindicatedwhen there were advanced degenerative changes in theradiocarpal or intercarpal joints, fixed carpal malalign-ment, or disabling trophic disturbances causing limitedover-all function of the hand.

As shown in Table I, there were twelve malunionsafter a Colles fracture, five after a Smith fracture, andthree after a comminuted fracture of the distal end of theradius. Eleven wrists with a Colles fracture had an in-creased dorsal tilt averaging 34 degrees (range, 25 to 55degrees), and the twelfth wrist (Figs. 5-A and 5-B) with Colles fracture initially had been over-reduced and thenfailed to unite, with a resulting volar tilt of 21 degrees anda radial deviation of 27 degrees at the time of osteotomy.Although there was increased palmar angulation in thiswrist, it was included in the Colles group because of theinitial fracture type. In these twelve wrists, the radial de-viation averaged 12.6 degrees (range, 2 to 27 degrees) andthe radial shortening averaged 7.3 millimeters (range, twoto twelve millimeters).

In the patients with a Smith fracture, the average

FIG. I-A

Diagram of the opening-wedge osteotomy performed for the malunitedColles fracture. Note the interposition of the wedge-shaped corticocan-cellous iliac graft and the internal fixation with a small-fragmentT-buttress plate.

1165

volar tilt was 32 degrees (range, 20 to 40 degrees), theaverage radial deviation was 5.6 degrees (range, zero to 10degrees), and the average radial shortening was eight mil-limeters (range, three to fifteen millimeters).

In the patients with a comminuted fracture, the dorsaltilt was zero, 25, and 36 degrees; the radial deviation was45, 32, and 20 degrees; and the radial shortening was fif-teen, eighteen, and ten millimeters.

Fm. 1-B

Case 4. Radiographic appearance of the wrist before and after os-teotomy for a malunited Colles fracture.

Before osteotomy, ten of the twenty patients hadradiocarpal pain. Of these ten, nine had mild to moderatepain while attempting to position the wrist in forced pal-mar flexion or dorsiflexion, and one (Case 5, Fig. 7-A) hadsevere preoperative pain and a mild Sudeck dystrophy thatdeveloped during the initial treatment of the fracture. Theother ten patients had no radiocarpal pain but complainedof functional impairment due to a pathologically displaced

VOL. 64-A, NO. 8, OCTOBER 1982

TABLE I

Type of InitialCase Occupation Age, Sex Fracture Treatment

(Yrs.)

Preop.Preop. Radiographic Measurements* Level of Pain’j" Preop.

Dorsal Volar Ulnar Radial Radial Radio- Radio- CosmeticTilt Tilt Tilt De~,iat. Shortening carpal Ulnar Appearance¢

(Degrees) (Degrees) (Degrees) (Degrees) (ram)

Preop. Function of the Wrist (Affected/Normal) (Degrees) Radial OsteotomyPatmar Radial Ulnar Grip Darrach Surgical

Dorsiflex. Flex. Deviat. Deviat. Pronat. Supinat. Strength Graft Prec. Approach

1 Homemaker 26, F Colles Closed redue- 40 -- ,..lion andplaster cast

2 Manager 41, M Colles Closed reduc- -- 21¶tion andplaster cast

3 Mechanic 51, M Colles Closed redue- 30 --tion andplaster cast

4 Operator 31, F Colles Closed redue- 25 --tion andplaster cast

Closed redue- 30 --tion andplaster cast

Closed reduc- 31 --tion andpiaster cast

Closed reduc- 32 --tion andplaster east

8 Truck driver 30, M Colles Closed reduc- 55 --

5 Homemaker 51, F Colles

6 Mason 34, M Colles


9 Roofer 36, M Colles

10 Student 20, M Colles


12 House-painter 45, M Colles

13 Locomotive 48, M Smithconductor

14 Construction 40, M Smithoperator

15 Farmer

16 Carpenter

17 Secretary

18 Bdcldayer

19 Homemaker 65, F Comminuted Closed reduc-tion andplaster cast

20 Construction 34, M Comminuted Externaloperator fixation

32, M Smith

33, M Smith

40, F Smith

55, M Comminuted. "Pins andplaster"(BShler)

lion andplaster east

Closed reduc- 30 --tion andplaster cast

Closed reduc- 42 --tion and

Closed reduc- 25 -- ¯tion andplaster cast

Closed redue- 36 ---tion andplaster cast

Closed reduc- -- 40tion and



Closed reduc- -- 20

plaster east

Percutaneous -- 30pins andplaster cast

0 0

36

5 20

-2 27

10 15

18 7

7 18

15 10

23 2

5 20

22 3

15 10

13 12

1718

21 4

20 5

15 i0

16 9

25 0

--20 45

--7 32

5 20

5 + +++

9 -- ++ +++

10 -- ++ ++

2 -- - +

6 +++ - ++

5 - - ++

9 ++ + +++

12 ++ ++ +++

3 - - ++

l0 ++ + +++

5 - - ++

12 ++ ++ +++

15 +++ ++

12 ++ +

5 + +

5 - +

3 ++ - +

15 ++ +++ +++

18 -- + +++

12 ++ ++ ++

90/75 25/75

30/75 45/70

60/75 15/80

70/80 25/80

30/75 0/65

75/80 35/75

80/75 40/75 I0/15

90/75 5/70 20/10

60/80 15175 10/20

85/75 30/90 15/15

50/65 10/75 10/10

70/75 30/80 15/20

15/70 90/75 10/t0

10/80 60/75 15/20

5/75 70/70 10/15

25/70 60/75 10/15

20/80 45/70 10/15

30/70 15/75 40/15

45/65 10/70 30/10

35/75 5/70 5/10

30/15 10/40

35/20 10/35

20/15 15/40

20/20 30/35

15/10 15/30

15/15 25/35

30/40

5/35

30/35

20/35 65/85 50/90

15/30 75/80 . 80/85

10/30 35/80 70/90

80/80 85/90 10/30 lliac No Dorsal

60/85 45/90 15/45 lliac No Volar

40/80 70/85 12/40 lliac No Dorsal

80/85 90/90 18/26 lliac No Dorsal

60/85 70/90 5/25 lliac No Dorsal

85/90 80/85 25/50 lliac No Dors.el

75/90 70/85 10/25 lliac No Dorsal

40/85 55/90 15/42 lliac No Dorsal

80/80 75/90 18/34 lliac No Dorsal

I6/35 Iliac No Dorsal

5/15 lliac No Dorsal

21/52 lliac No Dorsal

20/40 70/80 5/85 17/43 Distal ulnar Yes Volar


20/35 75/85 70/90 15146 Olecranon No Volar

25/35 85/90 75/90 20/45 lilac No Volar

35/40 80/80 85/90 3/22 Local callus No Volat


5/25 50/80 25/85 7/18 Distal ulnar Yes Dorsal

10/30 65/85 50/90 12/47 Distal ulnar Yes Dorsal

TABLE 1 (Continued)

~ Postop. LevelPostop. Radiographic Measurements* of Pain’{" Postop.

Time to Length of "Dorsal Volar Ulnar Radial Radial Radio- Radio- CosmeticCase Healing Follow-up Tilt Tilt Tilt Deviat. Shortening carpal Ulnar Appearance~(Wks.) (Mos.) (Degrees) (Degrees) (Degrees) (Degrees) (mm)

Postup. Function of the Wrist (Affitctcd/Norlnal) (Degrees) CombinedPalmar Radial Ulnar Grip Reopera- Removal of Ability Final

Dorsiflex. Flex. Deviat. Deviat. Pronat. Supinat. Strength Complications tion Implant to Work Assessment§(kg39 (Per cent)

1 5.5 96 0 0 202 6 62 3 -- 203 6 55 4 -- 224 5 50 -- 7 185 6.2 42 3 -- 15

5 0 - - 65/75 70/75 15/15 30/35 80/855 0 - - - 75/75 65/70 15/20 25/30 80/853 3 -. - - 65/75 65/80 10/15 35/40 80/807 0 - - - 75/80 60/80 20/20 35/35 80/85

10 0 +++ + 15/75 10/65 5/10 15/30 60/85

6 5 43 -- 5 23 2 0 - -

7 5.3 46 0 0 24 1 0 - -

8 7 25 0 0 10

9 6 27 -- 7 2510 4.5 25 0 0 2311 7 24 5 -- 2!

12 6.3 24

13 6 74

14 5.8 54

15 6.5 4816 6 2417 6 26

18 7.5 72

19 6 30

65/80 55/75 10/15 30/35 85/90

75/75 70/75 15/15 30/40 85/85

20 6.5 24

15 4 - + + + 65/75 45/70 10/10 25/35 75/85

0 -2 - 60/80 65/75 10/20 35/35 80/802 0 - 70/75 75/90 10/15 35/40 80/854 1 - 60/75 35/75 15/15 25/30 75/80

0 0 15 I0 1 - - - 60/75 45/80 15/20 30/30 70/85

-- 4 26 0 Darrach - - - 50/70 45/75proc.

0 0 30 0 Darrach - - 45/80 60/75

-- 9 20 5 0 - - 55/75-- 5 23 2 0 - - 55/700 8 25 0 0 - - 60/805 -- 10 15 Darrach + + -- + 40/70

proc.-- 9 10 15 Darrach . + - - 40/65

proem\.,6 -- 15 10 Darrach ++ -- - 50/75

I0/10 35/40 80/80

10/20 40/35 75/80

60/70 t5/15 30/35 85/8540/75 15/15 30/35 90/90

45/70 10/15 35/40 80/8025/75 20/15 20/35 70/85

40/70 I0/10 20/25 75/80

35/70 5/10 15/30 80/80

75/85

80/90 29/35 --

90/90 41/47 --

85/90 38/42 --

85/90 18/25 --

90/90 21/43 Acutehematoma

85/85 12/20 --

75/90 26/45 Tendinitis ofextensorpollicisIongus

90/90 30/36 -- -- Yes I00 A85/90 42/45 -- -- Yes 100 A75/85 40/45 -- -- Yes I00 A90/90 26/27 -- -- Yes 100 A65/90 7/20 Progressive Total wrist Yes 50 D

pain, radio- arthro-carpal plasty :-.]arthritis

85/85 43/48 Tendinitis of -- Yes 100 B

pollicisIongus

90/90 ~23/27 Hypertrophic Multiple Yes 100 A

plastics60/90 33/40 Painfuldistal Darrach Yes 100 C

sublux, of proc.ulna

80/90 35/37 -- -- Yes 100 B ~_]75/90 33/35 -- -- Yes 100 B80/85 12/18 Partial loss of -- Yes I00 B

volar tilt

(Is°)70/90 42/50 Partial loss of -- Yes 100 B

ulnar tilt(10o)

35/44 -- -- Yes 100 B

-- No 100 B

-- No I00 B

-- No 100 B

-- Yes 100 BSurgical Yes 75 C

drainage

-- Yes 1 O0 C

-- Yes 50 C

* The radiographic measurements were made according to Castaing’s modificatlon of the method of Gartland and Weriey. Radialdeviation of the articular surface of the mdins is defined as the difference between the average ulnar tilt (25 degrees) and the radialinclination of the tilted articular surface with respect to the perpendicular to the radial shaft in the frontal plane. A negative value forulnar tilt means that there is no ulnar inclination of the articular surface of the radius, but instead there i~ radial inclination so that theradial articular surface forms a negative angle with relation to the perpendicular of the radial shaft.

~" - = none; + = mild (there is pain at the extremes of the active range of motion of the wrist but the patient is neither physicallynor psychologically disturbed); + + = moderate (the patient is physically or psychologically disturbed, or both, due to pain in the wrist

during heavy manual labor); and + + + = severe (there is pain during activities of daily living and even at rest).~: - = no deformity (the appearance is symme~cal with that of the opposite wrist); + = mild deformity (the ulnar head is slightly

prominent and there is mild radial deviation); + + = moderate deformity (the ulnm- head is prominent and the hand is offset radially);and + + + = severe deformity (the ulnar head is prominent and there is severe radial deviation, shortening, and a so-called dinner-forkdefomfity).

§ See text.¶ The original deformity was ovcrcorrected.

1168 D. L. FERNANDEZ

flexion-extension arc of motion. Eleven of the twenty pa-tients also had pain at the level of the distal radio-ulnarjoint that was associated with more than nine millimetersof radial shortening. Radio-ulnar pain was noted by the

patients either during passive movement of the wrist whilethey were being examined or during forceful rotation ofthe forearm while they were working.

Preoperative assessment of wrist motion in the pa..

Fro. 2-ACase 15, a malunited S~nith fracture.

Fig. 2-BTwo years after treatment with a palmar opening-wedge osteotomy,

THE JOURNAL OF BONE AND JOINT SURGERY

CORRECTION OF POST-TRAUMATIC WRIST DEFORMITY IN ADULTS 1169

tients with a Colles fracture showed an average loss of52.9 degrees of palmar flexion and a loss of 9.6 degrees ofdorsiflexion when the affected and unaffected sides werecompared. In the patients with a Smith fracture, the aver-age losses were 8 degrees of palmar flexion and 60 de-grees of dorsiflexion, and in the patients with a corn-minuted fracture 61.6 degrees of palmar flexion and 33.4degrees of dorsiflexion were lost.

Pronation and supination before osteotomy were sig-nificantly reduced in ten of the twenty forearms. These werethe ones with radial shortening of more than ten millimeters(average, 12.6 millimeters) (Table I). In these ten forearmsthe average loss ofpronation was 46.5 degrees and the loss ofsupination averaged 59 degrees. Radial shortening of asmuch as six millimeters did not produce serious functionalimpairment of forearm rotation except in one patient (Case 5)with six millimeters of shortening, in whom a Sudeck dys-trophy developed during initial treatment of the fracture.Disabling limitation of ulnar deviation was present in threewrists with severe radial deviation of 20 degrees or more andradial shortening of twelve millimeters or more (Cases 8,18, and 20) (Table I).

Surgical Technique

Extra-articular malunion after fracture of the distalend of the radius generally produces deformities in morethan two planes. After a Colles fracture, the distal frag-ment is usually tilted dorsally in the sagittal plane and ra-dially in the frontal plane and is supinated in the horizon-tal plane. The amount of shortening depends mainly onthe extent of the comminution and of the impaction of thefragments of the metaphysis. The shortening of the radiusrelative to the ulna leads to subluxation of the distal radio-ulnar joint and painful impairment of pronation and supi-nation. Conversely, in a malunited Smith fracture thevolar tilt of the radial articular surface is increased andthere may be a pronation deformity with associated dorsalsubluxation of the distal end of the ulna.

Massive shortening of the radius and radial deviationof the hand without troublesome malalignment in the sagit-tal plane (less than 25 degrees) are common residual de-forrnities after a comminuted fracture.

Although a moderate loss of motion of the wrist maybe expected after an extra-articular fracture, the main

Preoperative planning of the 0steotomy. Top left: For correction in the sagittal plane, the dorsal tilt. (30 degrees in this patient) is measuredbetween the perpendicular to the joint surface and the long axis of the radius on the lateral radiograph. The Kirschner wires are inlxoduced so that theysubtend the angle that corresponds to the dorsal tilt plus 5 degrees of volar tilt (30 + 5 degrees = 35 degrees in this patient). Bottbm left: Afteropening the osteotomy by the correct amount, the Kirschner wires lie parallel to each other. Top right: For correction in the frontal plane, the amountof shortening (nine millimeters in this patient) is measured between the head of the ulna and the ulnar corner of the radius on the anteroposteriorradiograph. The lines for the measurement are perpendicular to the long axis of the radius. The ulnar tilt is reduced to i0 degrees in this patient.Bottom right: In order to restore the ulnar tilt to normal (average, 25 degrees), the osteotomy is opened more on the dorsoradial than on the dorso-ulnar side.

Grip strength was measured with a Schaerer .problems are the disabling displacement of the flexion-dynamometer and expressed as a per cent of the strength ofthe uninvolved hand. The average preoperative gripstrength in this series was 35.7 per cent (range, 11.6 to 69per cent) and the average loss of grip strength was 64.3per cent.

Another common complaint of all patients was theunacceptable appearance of the deformity.

extension arc of motion caused by the residual angulationin the sagittal plane and the symptoms arising from thesubl:~ixation of the distal radio-ulnar joint.

Patients usually ~0mplain of loss of palmar flexionafter malunion of a Colles fracture and loss of dorsiflexionafter’ a malunited Smith fracture. Significant loss of flexionor extension is a frequent sequela to a comminuted intra-


i170 D. L. FERNANDEZ

articular fracture or a fracture that is complicated by aSudeck dystrophy during initial treatment.

The aims of radial osteotomy are to restore functionand improve the appearance of the wrist by correcting thedeformity at the level of the old fracture site. For this pur-pose an opening-wedge 0steotomy that is transverse in thefrontal plane and oblique (parallel to the joint surface) the sagittal plane is used8 (Figs. 1-A and I-B). This os-teotomy allows correction of: (1) the volar tilt in the sagit-tal plane, (2) the ulnar tilt in the frontal plane, (3) the rota-tion deformity in the horizontal plane, and (4) shorteningof as much as twelve millimeters. By opening the os-teotomy on the dorsal and radial aspects of the radius, thebone is lengthened, improving anatomical relationships atthe level of the distal radio-ulnar joint, provided that thelength discrepancy between the radius and ulna is notgreater than twelve millimeters. A corticocancellous bonegraft from the iliac crest is cut to fit the bone defect so thatit has a triangular cross section in the sagittal plane and atrapezoidal cross section in the anteroposterior plane, andwill restore the physiological volar and ulnar tilts of thejoint surface. Internal fixation with a small buttress T-plateis usedto maintain correction and to allow early functionand rapid rehabilitation of the neighboring joints.

A careful preoperative plan and the use of Kirschnerwires to mark the angle of the deformity simplify the pro-cedure, and intraoperative radiographs are seldom neces-sary (Fig. 3). Radiographs of the uninjured wrist are usefulto determine the normal anatomical relationships of thedistal radio-ulnar joint in each patient. The presence of anulnar plus or minus variation on the opposite side shouldbe taken into consideration during preoperative planning,and an effort should be made to obtain anatomical restora-tion at the radio-ulnar joint.

Malunited Colles Fractures

:These malunions are approached through a Straightdorsoradial incision that is made parallel to the long axis ofthe radius. It begins at a point two centimeters distal to theLister tubercle and extends eight centimeters proximally inthe forearm. The radius is exposed between the extensorcarpi radialis brevis and extensor digitorum communistendons after .mobilizing and carefully retracting the exten-sor pollicis longus tendon. Exposure of the dorsal aspect ofthe radius should be subperiosteal, to provide good soft-tissue coverage of the plate and to avoid contact betweenthe internal fixation device and the extensor tendons.

The site of the osteotomy (2.5 centimeters proximalto the wrist joint) is marked with an osteotome. Usuallythe Lister tubercle is removed with an osteotome to pro-vide a flat surface on which to apply the plate. In accor-dance with the preoperative plan (Fig. 3), the firstKirschner wire is inserted four centimeters proximal to theosteotomy site and perpendicular to the long-axis of theradius. The second Kirschner wire is driven into the distalportion of the radius so that the angle subtended by it and

e first Klrschner wire is equivalent to the angle of the de-

fortuity in the sagittal plane.To be sure that the cut as seen in the sagittal plane is

parallel to the joint surface, a fine Kirschner wire is in-serted through the dorsal part of the capsule into theradiocarpal joint and along the articular surface of theradius to guide the direction of the osteotome or oscillatingsaw as the osteotomy is performed. As this is done, thevolar soft tissues are protected with subperiosteal retrac-tors. The osteotomy is then opened dorsally until the twoKirschn~r wires are parallel to one another. If placement ofthe wires has been correct (according to the angle calcu-lated from the preoperative drawing), restoration of thenormal volar tilt (5 to 10 degrees) of the distal radial ar-ticular surface is achieved when the wires are parallel inthe sagittal plane.

Correction in the frontal plane is accomplished byopening the osteotomy on the radial side until the gap cor-responds to the distance measured on the preoperativedrawing (Fig. 3). The reduction is then maintained tem-porarily with an oblique Kirschner wire that is insertedthrough the radial styloid process into the proximal frag-ment of the radius. Next, the bone graft is shaped to con-form to the dorsoradial bone defect and is inserted, makingsure that there is a snug fit. Any pronation or supinationdeformity should be corrected, before introducing thegraft, by rotating the distal fragment about the long axis ofthe radius.

The plate should be contoured to fit the surface of theradi~as perfectly. Fixation with two screws in each frag-ment offers enough stability for early unrestricted activemotion if the screws have a good hold. Otherwise, threescrews in each fragment or an additional oblique lag screwdriven from the radial styloid process across the osteotomysite :into the ulnar cortex of the proximal radial fragment isrecommended.

Malunited Smith Fractures

For correction of this deformity, a volar approach be-tween the flexor carpi radialis tendon and the radial arteryis employed, with detachment of the pronator quadratusmuscle from the radiusr. The pal.mar opening-wedge os-teotomy, grafting, and plating are then carried out on thevolar side (Figs. 2-A and 2-B). Thus,.by applying the platedorsally for malunited Colles fractures and anteriorly formalunited Smith..fractures, a buttressing effect of the plateis achieved in both injuries.

The distal end of the ulna is resected wheri the radialshortening is more than twelve millimeters, when there aredegenerative changes of the distal radio-ulnar joint due toarticular fracture of the sigmoid notch, or when trouble-some subluxation of the distal end of. the ulna is present.However, whenever possible the distal radio-ulnar jointshould be preserved, especially in patients who performheavy manual labor, since a common complaint after the:Darrach procedure in young adults is the decrease in gripstrengtha’s’~z. If the distal end of the ulna is resected, it isused as the graft to fill the osteotomy gap.



FI~. 4-ACase 19, a malunited Colles fracture with eighteen millimeters of radial shortening, 32 degrees of radial deviation, and 25 degrees of dorsal tilt in

a sixty-five-year-old woman who wanted cosmetic correction of the deformity.

Ft~. 4-BBecause it was not possible to restore the length of the radius, a Darrach procedure was combined with a radial osteotomy to ensure realignment of

the hand in the frontal plane.


1172 D. L. FERN/~NDEZ

Malunited Comminuted Fractures

Simple resection of the distal end of the ulna or ashortening osteotomy of the ulna to correct a deformity of

the wrist due to severe shortening of the radius (of moretitan fifteen millimeters) or radial deviation of the distalfragment of the radius (of more than 30 degrees) does not

F~. 5-ACase 2, a non-union of a Colles fracture with 21 degrees of volar tilt, 27 deg:rees of radial deviation, and nine millimeters of radial shortening.

FI~. 5-B

Radiographic appearance of the wrist five y,ears after corrective osteotomy.



re-center the hand in the frontal plane. Both resection ofthe distal end of the ulna and osteotomy of the radius arenecessary to obtain a good cosmetic result under these cir-cumstances (Figs. 4-A and 4-B). Correction of the radialdeviation of the distal end of the radius realigns the carpusso that the long axis of the third metacarpal coincides withthe long axis of the radius. Simple resection of the distalend of the ulna may improve pronation, supination, andulnar deviation, but the hand remains radially offset in re-lation to the long axis of the forearm, so that the wrist stillappears deformed.

Postoperative Care

Postoperatively the wrist is immobilized in a volarplaster splint until the soft tissues have healed, usually bytwo weeks after operation. The patient is then encouragedto perform active exercises of the wrist, initially super-vised by a physiotherapist, but is not allowed to lift heavyobjects until healing of the osteotomy has been confirmedradiographically. Otherwise, free use of the hand is per-mitted for everyday activities and returning to heavy man-ual work is recommended at eight to ten weeks after oper-ation.

Exceptionally, if absolutely stable fixation is notachieved due to local osteoporosis, additional immobili-zation in a circular plaster cast may be indicated. Thissituation may arise if the corrective osteotomy is per-formed too soon after initial treatment of the fracture. Irecommend that osteotomy not be performed until five tosix months after the fracture, when the maximum possiblemotion of the wrist has been regained with physiotherapy.At that time the soft tissues are in ideal condition, withouttrophic disturbances, and there is radiographic evidence ofdecreased osteoporosis. The plate and screws are removedthree months after operation, especially when they are onthe dorsal aspect, to avoid tethering of the tendon or ten-dinitis of the extensor policis longus.

Results

For this study, the results were assessed two to eightyears (average, 3.6 years) after osteotomy. All of the pa-tients were .evaluated for pain, range of active motion, gripstrength, and appearance of the wrist. There was a directcorrelation between the results in these four categories.For example, apatient with incomplete correction of thedeformity and persistent incongruity of the distal radio-ulnar joint continued to have pain in this joint duringforceful pronation or supination, decreased grip strength,and an unsatisfactory cosmetic result. Patients werequestioned as to whether they had pain at rest, during nor-mal activities of daily living, or only during heavy manualwork. The cosmetic result was assessed by comparing thepreoperative and postoperative appearances of the wrist,using photographs of the preoperative deformity.

Detailed information from the postoperative assess-ment is shown in Table I. All malunions with an increaseddorsal tilt were operated on through a dorsal approach, and

those with an anterior tilt were operated on through an an-teric,r incision. In one patient (Case 18) who had radialdeviation and fifteen millimeters of shortening after acomminuted fracture, a volar approach was used. All os-teotomie.s were fixed with a plate and screws and an inter-posed graft. In thirteen patients the graft was taken fromthe iliac crest; in five, from the resected distal portion ofthe ulna; in one, from the olecranon; and in one, from thelocal callus mass.

The average time to healing was six weeks (range,4.5 to seven weeks). The criteria used to establish healingwere: the absence of pain, the presence of periosteal bridg-ing callus at the osteotomy site, and radiographic evidenceof s~:ability of the internal fixation material. All patientshad functional aftertreatment once the wound had healed,except for one with osteoporosis whose wrist was:im-mobilized in a forearm cast for five weeks.

Radiographic measurements that were made after theosteotomy had healed showed significant improvement inthe position of the radial articular surface in most patients.Thus, at follow-up of the patients with a Colles fracture,there was a volar tilt of 5, 7, and 7 degrees in three and ofzero degrees in five, while in the other four there was aresidual tilt that averaged 3.75 degrees (range, 3 to 5 de-gree:s). Furthermore, for all twelve wrists with a Collesfracture, the average residual radial deviation was 5.3 de-grees (range, zero to 15 degrees) and the radio-ulnarlength discrepancy averaged 0.58 millimeter (range, -2to four millimeters).

In the five forearms with a Smith fracture, examina-tion at follow-up showed that the volar tilt was corrected toan average of 5.2 degrees (range, zero to 9 degrees), andthat there were no overcorrections into .dorsal tilt. Theradius was restored to normal length and the anatomical re-lationship of the distal radio-ulnar joint was re-establishedin three forearms, while in the other two a primary Darrachprocedure had been performed.

At follow-up of the three forearms with a comminutedfracture, the dorsal tilt was zero degrees in one while in theother two it was reduced to 5 and 6 degrees. The residualradial deviation was 15, 15, and 10 degrees; an averagereduction of 19 degrees compared. With the preoperativestatus. The length discrepancy before osteotomy had beenfifteen, eighteen, and twelve millimeters. A primary Dar-rach resection was performed in all three wrists becausethe shortening exceeded twelve millimeters in two andthere were degenerative changes in the sigmoid notch inthe third.

The appearance of the wrist in fourteen of the twentypatients was restored to normal compared with the unaf-fected side. In four other wrists that were tr6ated by os-teotomy combined with a Darrach resection, there was noresidual deformity but the normal prominence of the distalend of the ulna was missing (Figs. 4-A and 4-B). In thetwo remaining wrists, a mild deformity that was charac-terized by slight radial deviation (15 degrees) persisted dueto insufficient correction in the frontal plane.


~1174 D. L. FERNANDEZ

Of the ten patients who had had pain in the radiocar-pal joint preoperatively, three (Cases 18, 19, and 20) whohad had a comminuted fracture and primary intra-articularinvolvement still had moderate radiocarpal pain duringheavy manual work. Another patient (Case 5, Figs. 7-A,7-B, and 7-C) had increasing pain and loss of functionafter osteotomy due to progressive degenerative changesand a fixed dorsiflexion carpal-collapse deformity. Twoyears after the osteotomy, this patient had a total arthro-plasty of the wrist and the outcome was satisfactory.

Two patients had persistent pain in the distal radio-ulnar joint. One (Case 5) had gained very little forearm ro-tation (5 degrees) after operation despite restoration of ra-dial length. The lack of improvement in this patient wasdue to a mild Sudeck dystrophy that had developed duringinitial treatment, with resultant retraction and fibrosis ofthe capsular and ligamentous structures of both theradiocarpal and the radio-ulnar joint. Rotation of theforearm was subsequently restored to normal by resectionof l:he distal end of the ulna during total wrist arthroplasty.

FIG. 6-A

..... Fro. 6-B~ ~ Figs. 6-A and 6-B: Case 7. Radiographs made before and two years after con’ection of a malunited Colles fracture. The result was rated as ex-~ }i cellent.

~ THE JOURNAL OF BONE AND JOINT SURGERY


The other patient (Case 8) had a secondary Darrach proce-dure because of residual dorsal subluxation of the distalend of the ulna and limited supination. This patient had afair result.

Over-all there was a marked improvement of therange of flexion and extension in fifteen patients, whilefive (Cases 5, 8, 18, 19, and 20) (Table I) showed little no improvement.

The displaced flexion-extension arc of motion of thetwenty wrists was restored to normal in nineteen, while inthe other wrist (Case 5) the postoperative gain was only degrees of palmar flexion.

At follow-up, the average range of dorsiflexion was63 degrees in the patients with a Colles fracture, 53 de-grees in those with a Smith fracture, and 40 degrees inthose with a comminuted fracture, while the average rangeof palmar flexion was 50 degrees in those with a Collesfracture, 50 degrees in those with a Smith fracture, and33.3 degrees in those with a comminuted fracture.

The average grip strengths of the affected hands in thethree groups were expressed as percentages of the averagegrip strengths of the normal opposite hands before opera-tion and at follow-up. The preoperative and follow-up av-erages were: 40 per cent and 82.7 per cent in the patientswith a Colles fracture, 30.3 and 82.3 per cent in those witha Smith fracture, and 27.2 and 55.5 per cent in those witha comminuted fracture. Restoration of the ability to posi-tion the wrist actively in slight dorsiflexion and ulnar de-viation for maximum mechanical efficiency of the flexortendons and the elimination of pain were the main reasonsfor the improvement in grip strength.

Ten of the twenty patients whose average radialshortening was 12.6 millimeters had average losses of46.5 degrees of pronation (range, 35 to 70 degrees) and

degrees of supination (range, 5 to 70 degrees) before os-teotomy. At follow-up, nine of these ten patients had anormal range of pronation-supination and one (Case 8) hadpersistent limited rotation of the forearm (pronation, 75degrees and supination, 60 degrees) due to residual dorsalsubluxation of the distal end of the ulna. Of the other tenpatients with shortening of less than six millimeters, onlyone had significant preoperative limitation of rotation ofthe forearm (Case 5). Thus, at follow-up rotation was re-stored to normal in nine of these ten wrists while there wasa 50-degree loss of rotation compared with the unaffectedwrist in one (Case 5).

Based on evaluations of pain, range of active motion,grip strength, and appearance, four result ratings were es-tablished (Table I). An A or excellent rating was given to awrist with no pain, normal or almost normal motion, gripstrength of not less than 80 per cent of normal, and novisible deformity (Figs. 6-A, 6-B, and 6-C). A B or goodrating was given to a wrist with no pain, moderate limita-tion of motion (not less than 65 to 70 per cent of normal),grip strength of not less than 70 per cent of normal, and nodeformity. A C or fair rating was given to a wrist withmode~cate pain during work activities, limitation of motionof 40 to 65 per cent of normal, grip strength of 50 to 70 percent of normal, and mild deformity. A D or poor ratingwas given to a wrist that was considered to be a failure oftreatment because of persistence of pain during work ordaily activities, severe loss of motion (less than 40 per centof normal), and reduction of grip strength to less than 40per cent of normal or associated stiffness of the fingerjoints with impairment of function of the hand. The over-all results in the twenty patients were five excellent, tengood, four fair, and one poor rating.

The causes of the unsatisfactory results were primary

FIG. 6-C

Case 7. At follow-up, palmar flexion and dorsiflexion were normal and rotation of the forearm on the two sides was symmetrical.



intra-articular involvement after a severely comminutedfracture in three patients (Cases 18, 19, and 20), painfulsubluxation of the distal end of the ulna in one (Case 8),and pre-existing stiffness and degenerative changes in theradiocarpal and intercarpal joints in one (Case 5).

In the three patients who had a comminuted fracturewith intra-articular involvement, there was minimum im-provement of flexion and extension after radial osteotomycombined with a Darrach procedure, but the external ap-

pearance and rotation of the forearm were improved. In thepatient with subluxation of the ulna there was insufficientlengthening of the radius and probably overcorrection ofthe distal radial fragment which produced a pronation de-formity, while in the patient with degenerative changes(Figs. 7-A, 7-B, and 7-C) the osteotomy procedure wasdefinitely not indicated since the extent of the radiocarpaland intercarpal degenerative changes and the severity ofthe joint stiffness were underestimated prior to operation.

Fro. 7-A

Figs.. 7-A and 7-B: Case 5.. This.patient. had a poor result after osteotomy because of nreo~erative narrowin of the radioc al joint and fixedmalahgnment of the carpus m dors~flex~on. The wrist remained painful after operation ~nd t~e arthritis progr~sed, alp a



Complications

Persistent postoperative edema and delayed restora-tion of motion of the fingers were common when the os-teotomy of the radius was combined with resection of the

distal end of the ulna. There was one postoperativehematoma (Case 18)which was associated with massiveswelling of the distal part of the forearm and was drainedsurgically forty-eight hours after osteotomy.

Tendinitis of the extensor pollicis longus was ob-served in two wrists in which there was direct contact ofthe tendon with the dorsal plate. The symptoms were re-lieved after the plate was removed, and no late tendon rup-tures occurred.

There were no superficial or deep infections in thisseries. Partial loss of correction was observed radiographi-caliy in two patients who had osteoporotic bone. In one,the initial correction of the volar tilt to 10 degrees wasgradually lost during the first two weeks. The resultingdorsal tilt of 5 degrees did not affect the late result. In theother patient, the initial correction of 25 degrees of ulnarinclination in the frontal plane was reduced to 15 degreesdue to collapse of the graft on the lateral side of the radius.

Subsequent Operations

The internal fixation device was removed from seven-teen of the twenty wrists. Three volar plates were left inplace. There were four second operations: one to drain ahematoma, one total wrist arthroplasty, one secondaryDarrach procedure, and one for multiple z-plasties to cor-rect a dorsal scar contracture.

Discussion

Several authors have advocated corrective osteotomy

for rnalunited fractures of the distal end of the radius inorder to improve function, deformity, and disability of thewristz,8,1°’12’14. Campbell described excellent cosmetic andfunctional results in eleven of nineteen patients in whom atransverse osteotomy with interposition of a graft wasused.. The graft was taken from the prominent medial bor-der .of the ulna and the distal radio-ulnar joint waspreserved. Although detailed data on postoperative as-sessraent of wrist function were not presented, it appearedthat this procedure gave better functional and cosmetic re-sults than those after simple osteotomy that only correctedthe backward angulation of the articular surface of theradi~ts.

Speed and Knight recommended the use of an in-tramedullary bone peg or dual onlay grafts to avoid loss ofcorrection in wrists with severe deformity or osteoporosis.This method of fixation, however, did not allow unre-stricted motion of the wrist postoperatively, and externalimmobilization was maintained until union was confirmedclinically and radiographically. Internal fixation was ad-vocated by these authors in "all but the simplest real-unions".

Merle d’Aubign6 and Tubiana12 described satisfac-tory results in twenty-seven wrists that were treated withso-called facet osteotomy, which was designed to restoreradial length without the need of a graft. However, the dis-tal ,end of the ulna was resected in seventeen of thesetwenty-seven wrists. By virtue of its shape this osteotomyproduces a slight palmar displacement of the distal frag-ment with respect to the shaft of the radius, and permits nocorrection in the frontal plane. One oblique Ki~schner wirewas used for fixation and postoperatively the wrist wasimmobilized in a forearm cast for ~wo months. The results

FIG. 7-C

Case 5. Because of progressive pain and loss of motion, a total wrist arthroplasty was performed two years after the radial osteot0mY. Thefunctional result was adequate. (Reprinted courtesy of Dr. U. Biichler, Chief., Hand Surgery Service, Inselspital, Berne.)



in that series were presented as mean values and per-centages of improvement of motion of the wrist and gripstrength, and were compared with results after twenty-seven Darrach procedures. There were no radiographicmeasurements or assessments of residual pain. The authorsconcluded that osteotomy of the radius combined with re-section of the distal end of the ulna offered better cosmeticand functional results than did a Darrach resection alone,but that the disadvantage was the prolonged period ofpostoperative immobilization. They also concluded thateven though the Darrach procedure gave satisfactoryfunctional results after a short period of immobilization,the cosmetic correction was insufficient when so-calledimportant dorsal angulation was present.

The over-all results in my series showed that os-teotomy is a valuable procedure for the treatment ofextra-articular malunions of the distal end of the radiusprovided that there is an adequate preoperative range ofmotion (that is, not less than 70 per cent of normal) andthere are no degenerative changes in the radiocarpal joint.The improvement in flexion and extension after osteotomyfor malunion of a comminuted fracture was less satisfac-tory. Both an osteotomy and a Darrach procedure werefound to be necessary in five of the twenty wrists in theseries, and in all three of the wrists with severe radialshortening (more than twelve millimeters). Rotation of theforearm was improved if normal radial length was ob-tained without residual subluxation of the distal end of theulna. Complications and failures were due either totechnical errors or to the improper selection of patients

who had degenerative changes in the radiocarpal and inter-carpal joints or marked osteoporosis prior to operation.The main advantages of this technique are the maintenanceof correction by a tight-fitting bone graft and the rigid in-ternal fixation, which allows early unrestricted active mo-tion of all joints in the extremity. Predictable anatomicalresults can be expected if the procedure is executed inaccordance with a careful preoperative plan based onart analysis and measurements of the preoperative radio.-graphs. I believe that this preoperative plan is of extremeimportance because it allows calculation of the exactanaount of correction in the frontal and sagittal planes, theamount of lengthening, and the size of the graft needed ineach patient. Although the need for removal of the plateand screws in a second operation is a disadvantage, this isbalanced by the rigid fixation which offers stability, allowsearly motion, and reduces the need for both thephysiotherapy and the rehabilitation that often are neces-sary after six to eight weeks of immobilization of the wrist.

The operation is recommended for young, manuallyactive patients with significant deformity and functionalimpairment of the wrist and is considered to be a recon-structive procedure that is designed to restore to normalthe anatomy of the distal end of the radius and its relation-shiip to the ulna. Radial osteotomy is not recommended inthe presence of advanced degenerative changes, fixed car-pail malalignment, osteoporosis, or trophic disturbances ofthe hand. Radial osteotomy does not replace the Darrachprocedure, which still has a role in the treatment of mal-unions after Colles fractures in elderly patients.

References1. BOYD, H. B., and STONE, M. M.: Resection of’the Distal End of the Ulna. J. Bone and Joint Surg., 26: 313-321, April 1944.2. CAMPBELL, W. C.: Malunited Colles’ Fractures. J. Am. Med. Assn., 109:q 105-1108, 1937.3. CASTAING, J.: Les fractures r6centes de l’extr6mitd infdrieure du radius chez l’adulte. Rev. chir. orthop., 50: 581-696, 1964.4. COONEY, W. P., III; LINSCHEID, R. L.; and DOBYNS, J. H.: External Pin Fixation for Unstable Colles’ Fractures. J. Bone and Joint Surg., 61-A:

840-845, Sept. 1979.5. DARRACH, W.: Partial Excision of Lower Shaft of Ulna for Deformity following Colles’s Fracture. Ann. Surg., 57: 764-765, 1913.6. ELLIS, JAMES: Smith’s and Barton’s Fractures. A Method of Treatment. J. Bone and Joint Surg., 47-B(4): 724-727, 1965.

--7. FERNANDEZ, D. L., and M~DER, G.: Die Behandlung der Smith-Frakturea. Arch. orthop. Unfall-Chir., 88: 153-161, 1977.8. FERNANDEZ, n. L.; ALBRECHT, H. U.; and SAXER, O.: Die Korrekturosteotomie am distalen Radius bei post~aumatischer Fehlstellung. Arch.

orthop. Onfall-Chir., 90: 199-211, 1977.9. GARTLAND, J. J., JR., and WERLEY, C. W.: Evaluation of Healed Colles’ Fractures. J. Bone and Joint Surg., 33-A: 895-907, Oct. 1951.10. HOHMANN, G.:Tn Hand und Arm: Ihre Erkrankungen und deren Behandhmg, pp. 169-180. Mfinchen, Bergmann, 1949.11. MERLE D’AUB1GNI~, R., and JOUSSEMET: A propos du traitement des cals vicieux de l’extr6mit6 inf6riem’e du radius. M6m. acad. chit., 71:

153-157, 1945.12. MERLE D’AUBIGNI~, R., and TUBIANA, R.: S6quelles de traumatismes du poignet, in Traumatismes anciens. G6n6ralit6s membre sup6rieur, pp.

361-376. Paris, Masson, 1958.13. MILCH, HENRY: Cuff Resection of the Ulna for Malunited Colles’ Fracture. J. Bone and Joint Surg., 23:31 I-313, April 1941.14. SPEED, J. S., and KNIGHT, R. A.: Treatment of Malunited Colles’s Fractures. J. Bone and Joint Surg., 27: 361-367, July 1945.


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