Non union Lower end Radius

Vinod Naneria

Girish Yeotikar

Arjun Wadhwani

Choithram Hospital & Research Centre, Indore , India

Purpose

• Reporting three cases of non-union of fracture lower end radius.

• It is extremely rare condition

• Difficult to pinpoint the etiological cause.

• No single or multiple factors could be indentified.

• None had any co-morbidity or risk factor.

Early suspicion?

• When x-rays at 6 weeks showing clear fracture line with no attempt at union then it should be suspected for possible non union.

A clear fracture line with no callous at 6 weeks

Cases in brief

• All the three patients have different presentations.

• Cases one and two were initially treated properly.

• Case one had failed open reduction and bone grafting.

• Case two refused open reduction in small district place hence waited for six months.

• Case three refused even initial treatment.

Introduction

• Distal radius fractures are the most frequent ones on the upper limb.

• Account for 10 to 12% of all fractures of the skeleton.

• Represent 74.5% of all fractures of the forearm, with an approximate incidence of 1:10.000 individuals.

Incidence

• Watson-Jones reported 1 case in 3199 cases of fracture distal radius in 1942.

• Barcon and Kurtzke reported incidence as 0.2% in a study of 2000 cases fractures of lower end radius, in 1953.

Exact cause is not known

Soft tissue interposition?

General Risk factors:

• low-energy fractures,

• Impaction of metaphysis.

• DM, smoking, alcohol, collagen disorder,

• Obesity,

• Improper treatment

• Over distraction by ex fix

• Osteoporosis.

Recommonded Surgical principles

• Debridment of the nonunion, removing all fibrous and synovial interposed tissues.

• Removing the sclerotic end caps,

• Intramedullary canal is opened on both sides.

• Deformity in the sagittal and coronal planes should be corrected by an opening wedge.

Surgical principles

• Radial deviation deformity is corrected by lengthening the Brachioradialis and Flexor Carpi Radialis tendon.

• The use of Locking plates allows for more points of fixation in case of small distal.

• There is usually a larger amount of bone in the radial styloid portion of the distal fragment that can be used for internal fixation.

Surgical principles

• Tri-cortical opening wedge graft will provide intrinsic stability because of the tightening of the soft tissue.

• Cancellous bone graft should be used.

• For severe shortening of the distal radius that cannot be corrected, resection of the distal ulna (Darrach procedure).

Wrist arthrodesis

• Insufficient bone for fixation.

• When there are fewer than 6 mm of bone between the lunate facet of the distal radius articular surface and the fracture site.

• Pre-existing arthrosis of radio-carpal joints.

• Failed attempt of fixation of non union.

Case one

• 42 years old female.

• Low energy trauma.

• Fracture lower end radius

• Treated conservatively by closed reduction and pop casting in Dec 2012.

Dec 2012

March 2013

Close reduction and POP

Early sign

March 2013Open reduction, K-wire fixationBone graftingPOP cast

June 2013Excision lower end ulnaRemoval of K-wires

July 2013

Severe Palmer flexion and ulnar deviation deformity

DorsalPalmer/voral

Ulnar Radial

Palmer surface

Dorsal surface

Oct 201310 weeks Post surgeryMP joint flexion ↑Ex-fix removedPhysio-continuePatient’s satisfaction goodWrist mobilizationstarted.

After 6 months

Case two

• 50 years old female

• Low energy injury

• Sustained fracture lower end radius

• Pop cast for six weeks

• Progressively increasing deformity following removal of plaster.

• X- rays after six months following fracture showing non-union.

Established non union

Six month old injury

Surgery

• Volar exposure

• Removal of scar tissue and clearing of bone ends.

• Release of soft tissue contractures.

• Shortening of ulna and plating.

• Plating of radius with bone grafting.

Feb 2013

April 2014

Sept 2013

Case three

• 40 years old Female,

• Sustained fracture lower end radius on 13th Sept 2014.

• Received no treatment.

• No co-morbidity.

• Chief complaint was deformity of wrist.

• X-rays on 11th Nov 2014 showing delayed union

• Clinically no disability.

• Patient refused corrective surgery.

13th Sept 2014

11th Nov 2014

Early sign of potential nonunion

Comments

• The disability is minimal

• Very little / no pain

• Cosmoses is only complaint

• Acceptance for surgery is poor

• Hence delayed / no treatment

References

• Fernandez DL, Ring D, Jupiter JB. Surgical management of delayed union and nonunion of distal radius fractures. J Hand Surg 2001;26A:201e9.

• Chapman MW. Principles of treatment of non-unions and malunions. In: Chapman MW, editor. Chapman’s Orthopedic Surgery. 3rd edition. Lippincott

• Williams and Wilkins; 2001. p. 847e66.

• Segalman KA, Clark GL. Un-united fractures of the distal radius. A report of 12 cases. J Hand Surg 1998;23A:914e8.

• Bacorn RW, Kurtzke JF. Colle’s fracture. A study of two thousand cases from the New York State Workmen’s Compensation Board. J Bone Joint Surg 1953;35A: 643e58.

• McKee MD, Waddell JP. Non-union of distal radial fractures associated with distal ulnar shaft fractures: a report of four cases. J Orthop Trauma 1997;11: 49e53.

• Smith VA, Wright TW. Nonunion of the distal radius. J Hand Surg 1999;24B: 601e3.

• Eglseder Jr WA, Elliott MJ. Non-union of the distal radius. Am J Orthop 2002;31: 259e62.

References• Harper WM, Jones JM. Non-union of Colle’s fracture: report of 2 cases. J Hand Surg

1990;15B:121e3.

• Kwa S, Tonkin MA. Nonunion of a distal radial fracture in a healthy child. J Hand Surg1997;22B:175e7.

• Ring D, Jupiter JB. Nonunion of the distal radius. Tech Hand Up Extrem Surg 2002;6:6e9.

• Prommersberger KJ, Fernandez DL. Non-union of distal radius fractures. Clin Orthop2004;419:51e6.

• Prommersberger KJ, Fernandez DL, Ring D, et al. Open reduction and internal fixation of un-united fractures of the distal radius: does the size of the distal fragment affect the result? Chir Main 2002;21:113e23.

• Kaempffe FA, Wheeler DR, Peimer CA, et al. Severe fractures of the distal radius: effect of amount and duration of external fixator distraction on outcome. J Hand Surg1993;18A:33e47.

• Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg 2002;27A:205e15.

• Leung F, Zhu L, Ho H, et al. Palmar plate fixation of AO type C2 fracture of distal radius using a locking plateda biomechanical study in a cadaveric model. J Hand Surg 2003;28B:263e6.

• Jakob M, Rikli DA, Regazzoni P. Fractures of the distal radius treated by internal fixation and early function. A prospective study of 73 consecutive patients. J Bone Joint Surg2000;82B:340e4.

DISCLAIMER

Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India. It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal. Depending upon the x-rays and clinical presentations viewers can make their own opinion. For any confusion please contact the sole author for clarification. Every body is allowed to copy or download and use the material best suited to him. I am not responsible for any controversies arise out of this presentation. For any correction or suggestion please contact naneria@yahoo.com