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Archives of Orthopaedic

Arch Orthop Trauma Surg (1988) 107:301-308


and Traumatic Surgery
Springer-Verlag 1988

Corrective Osteotomy of the Distal Radius After Fracture to


Restore the Function of Wrist Joint, Forearm, and Hand

M Roesgen and G Hierholzer


Berufsgenossenschaftliche Unfallklinik Duisburg-Buchholz (Director: Prof Dr G Hierholzer), Gro Benbaumer Allee 250,
D-4100 Duisburg 28, Federal Republic of Germany

Summary Eighty-two patients suffering from a se- 80 % lie B sich eine gute oder sehr gute Funktion der
vere deformity of the distal radius were operated on Hand mit wiederhergestellter Greiffunktion nach-
in the course of the past 7 years The corrective os- weisen Bei 5 Patienten konnte die Gebrauchsfihig-
teotomy was done by implanting a corticocancellous keit der Hand nicht ausreichend erhalten werden.
bone graft to restore the correct angle of the joint Bei 2 dieser Patienten trat postoperativ eine Infek-
surface and the correct length of the radius In addi- tion auf, die chirurgisch nach Metallentfernung sa-
tion to this, a buttress T-plate was used, which could niert werden konnte Dennoch ist bei allen Patienten
be removed 6 months later In 80% of the cases the gegenilber dem priloperativen Zustand eine Besse-
results with regard to the function of the patients' rung der Handfunktion und des Greifverm 6 gens er-
hands were good The operative technique is standard- kennbar Eine Altersbegrenzung fiir die Operation
ized It is possible to perform this kind of operation wurde nicht gezogen, da insbesondere der alte Mensch
on patients of any age, and the procedure can check auf den vermehrten Gebrauch der oberen Extremitit
Sudeck's atrophy When the obvious disability of the angewiesen ist Eine durch Schmerz und Fehlstellung
forearm is corrected the mobility of the wrist joint is unterhaltene Sudeck'sche Dystrophie wird mit dem
simultaneously improved. operativen Eingriff durchbrochen Indem die listhe-
tisch st 6 rende Fehlstellung der Hand beseitigt wird,
werden gleichzeitig die Beweglichkeit des Handge-
Zusammenfassung Von 1981 bis 1987 wurden 84 lenkes und die Gebrauchsfahigkeit der Hand wieder-
Korrekturosteotomien der kbrperfernen Speiche bei hergestellt.
82 Patienten durchgefiihrt Die Indikationen waren
durch schwere posttraumatische Fehlstellungen der
k6 rperfernen Speichengelenkflhche mit Abkippung
nach speichenwdrts, nach streckseitig oder hohlhand- Conservative treatment according to B6hler ist most
seitig und begleitender Verkirzung der Speichenlhnge commonly employed in cases of distal radius frac-
gegeben Um die komplexen Fehlstellungen zu besei- ture However, it is not successful if the reduction
tigen, wurde die Osteotomie in Hohe des ehemaligen cannot be maintained The fracture then heals in a
Bruchspaltes ca 1 Querfinger proximal des Hand- malposition, accompanied by limited mobility of the
gelenkspaltes vorgenommen Der Osteotomiespalt wrist joint (Fig 1).
wurde aufgeklappt, ein cortico-spongioser Becken-
kammspan eingepa 13t und eine Kleinfragment-T-
Platte im Sinne der Abstiitzungsosteosynthese volar
Pathophysiology
bzw dorsal plaziert Die Metallentfernung erfolgte
6-10 Monate spiter Bei der Nachuntersuchung wur- At the moment of the accident the radial base breaks
den Beschwerden, R6 ntgenbefund und klinische Un-
down, compressing the bone l2, 7 l The joint surface
tersuchung in 4 Wertigkeitsstufen eingeordnet Bei
shows an abnormal tilt to the volar or dorsal and to
Offprint requests to: Dr M Roesgen the radial slide In addition, the radius is shortened.
302 M Roesgen and G Hierholzer: Osteotomy of Distal Radius After Fracture

The additional separation of the radioulnar joint


is painful and hinders pronation as well as supination.
Moreover, the capsule is painfully overstretched at
the convex side of the malformation The rupture and
the extension of the capsule, as well as the shortening
of the radial bone, cause instability, which increases
the pain and induces Sudeck's atrophy.

Indications for Operation

From the clinical point of view, we suggest that the following


findings are indications for a corrective osteotomy (Figs 3, 4):
1 Radiological malposition
* inclination of joint plane in volar or dorsal direction of
more than 20
* inclination of joint plane to radial side of more than 10
* shortening of radius by more than 3 mm, measured in the
radioulnar joint plane
2 Limited mobility of the wrist joint by about 50%
3 Aesthetic disorder
Fig 1 Severe deformity of wrist joint in two cases after malu-
nited distal radius fracture 4 Reduced grip strength, restrained use of the hand during
work
In order to reduce the bony malposition, to restore the mobi-
lity of the wrist joint as well as the grip, and to correct the de-
formation of the forearm we always have to concentrate on the
distal radioulnar joint Normal use of the hand can be achieved
only if this joint is put into a completely correct position The
aim of corrective osteotomy is to reduce the malposition and
the declination of the joint surface and, additionally, to restore
the length of the radius This will restore the function of the
hand l3, 9 l There are three techniques with varying degress of
success:
1 Resection of the ulnar head
2 Shortening osteotomy of the ulna
3.Corrective osteotomy of the radius

ad 1: Resection of the ulnar head is a very simple procedure l4,


10 l, but it causes further instability of the wrist joint The inter-
carpal and ulnocarpal ligaments are disconnected There is no
further hold for the ligamental wing, which provides part of the
Fig 2 Abnormal contact of triquetral and lunate bones with guidance for the wrist joint l 6l We do not recommend this
ulnar head Incongruity of scaphoid surface with styloid pro procedure, which, moreover, does not have any influence on
position of the radial
radial joint
cess of radius the
the position of the joint surface.
surface.

This shortening implies a corresponding lengthening


of the ulna with incongruity of the joint plane l 1, 3,
8 l The interaction of the three joint sections ie,
the radiocarpal, the ulnocarpal, and the radioulnar
section is deranged The step in the joint line and
the rupture of the articular disk allow direct contact
with the triquetral and/or the lunate bone l8 l This in-
duces an early and painful arthrosis (Fig 2) The mo-
bility of the wrist joint is reduced We have observed
that the patient's hand can move abnormally far in
the direction of the malnosition but hardly at all in
the opposite direction l 9l Fig 3 Normal ulnar and volar tilt of joint surface of radius
M Roesgen and G Hierholzer: Osteotomy of Distal Radius After Fracture 303

Fig 4 a Severe malposition of


wrist joint 2 years after injury;
radial deviation of about 300,
dorsal deviation of 30 , shorten-
ing by 4 mm b, c Interposition of
a triangular chip leads to correc-
tion of length and tilt in both di-
rections, post-op x-ray and 1
month later d Bony structured
radius, 4 months post-op; power-
ful grip restored at 1 year post-op

ad 2: The second possible procedure, i e , shortening osteo-


tomy of the ulna, does not achieve this aim either What can be 3 mm
restored is the correct position of the distal radioulnar joint,
but what remains is the malposition of the radius Moreover,
the bony healing is somewhat uncertain and takes a long time,
and the rate of malunion is high.

ad 3: Accurate repair of the anatomy and function of the wrist


joint is consequently possible only through corrective osteo-
tomy of the radius l 1, 3, 5, 9l. Fig 5 Two parallel lines perpendicular to axis of the radial
shaft show shortening of radius: distal line marks ulnar joint
surface, proximal line through ulnar corner of radius marks
shortening
Preoperative Planning

In each case it is necessary to take roentgenograms of the unin- of the joint surface of the radius With this point the dorsal or
jured wrist joint in two directions By comparing the roentgen- volar tilt of the radial joint surface is measured In the frontal
ogram of the injured with that of the uninjured wrist the angle view, two parallel lines, one through the ulnar corner of the ra-
of correction is measured Four positions must be corrected: dius and one through the joint plane of the ulnar head Both li-
1 The ulnar tilt of the radial plane nes are placed perpendicular to the axis of the radial shaft.
With these lines the lost length of the radius (Fig 5) can be
2 The volar tilt of the radial plane measured The axis of the radial shaft is indicated by one line
3 The rotation of the distal fragment in the frontal view and one line in the lateral view.
4 The length of the radial shaft
The points where the tilt of the radial joint surface should be Operative Technique
measured are: In the frontal view, (a) the tip of the styloid pro-
cess of the radius, and (b) the ulnar corner of the radius With The first thing to be decided is where to place the incision It
these points the diminished ulnar tilt of the radial joint surface must be dorsal if the deviation is dorsal, or volar if the hand is
is measured In the lateral view, the dorsal and the volar edge dropped From the dorsal approach the extension tendons
304 M Roesgen and G Hierholzer: Osteotomy of Distal Radius After Fracture

Fig 6 a Dorsal deviation of a wrist joint 5 months after


radial fracture; shortening of radius by about 8 mm, radial
tilt 5 , dorsal tilt 30 b Lengthening osteotomy with cortico-
cancellous chip via dorsal approach, using a buttress plate.
c Early removal of metal plate at 5 months post-op d Free
function 33 months post-op
Fig 7 a Compound fracture of distal radius and carpalia.
b One month after primary K-wire osteosynthesis; reduc-
tion not sufficient c Three months later, replacement of
radial base with chip and correct lengthening; insertion of
small T-plate via volar approach d, e Removal of metal
plate 8 months later f At 5-year follow-up no arthritis,
good function

have to be dissected between the extensor carpi radialis and ulnar and dorsal or volar direction are corrected at the same
the extensor indicis tendon The radial shaft is reached at a dis- time The two K-wires are now parallel Into the resulting de-
tance of 4 cm proximal to the wrist joint Preparing more dis- fect we implant a corticocancellous chip taken from the iliac
tally, one must avoid touching the extensor pollicis longus ten- crest It must be formed exactly like a triangle or a rhombus,
don, which must be detached out of its sheath The capsule of as measured from the preoperative drawing, and it must sup-
the wrist joint is dissected from its bony origin The joint is thus port the two osteotomy faces securely It acts as a buttress.
exposed and the cartilage can be seen Any step can be re- Now a small T-Plate is fixed to the radial shaft with three
cognized as a pathological deviation Now a K-wire has to be screws and at the radial base with one or two screws (Fig 6).
drilled dorsally into the radial shaft, perpendicular to its axis. From the volar approach the procedure is quite similar.
A second is drilled into the distal fragment with a declination The dissection is performed between the tendon of the flexor
to the first and corresponding to the angle which is intended to carpi radialis and the palmar tendon The superficial layer of
be corrected Then the osteotomy is performed with an oscillat- the quadrate pronator muscle has to be detached from the ra-
ing saw and a chisel at the level of the malposition and perpen- dial shaft The osteotomy, the insertion of the corticocancel-
dicular to the radial shaft The distal fragment is replaced under lous chips, and the osteosynthesis are done in the same manner
tension, and the shortening and the tilt of the joint plane in the as from the dorsal approach (Fig 7).
M Roesgen and G Hierholzer: Osteotomy of Distal Radius After Fracture 305
By this procedure we are able not only to correct the angle Table 3 Results of follow-up
of the joint surface in two directions but also to lengthen the
radius by about 15 mm and more Therefore, the osteotomy Level Result based on
must be not partial but total, and the surrounding tissue must Sub Radio Mobil Total
be mobilized because the scars may hinder the distraction The jective graphy ity
flexor and extensor tendons have no influence on the reduction com-
of the radial base Correct bony reduction provides the normal plaints
tension necessary for them to interact with each other, the
strength and the grip of the hand are restored. I 15 15 14 13 = 80%
II 44 45 40 43
III 8 8 11 9
Postoperative Treatment IV 8 2 5 5
In the operating room a dorsal plaster splint is fixed to the Total 70
forearm, including the heads of the metacarpal bones Two
days later, physiotherapy begins with active tension of the ex-
tensor and flexor muscles Slight movement of the wrist joint
and the fingers is allowed Two weeks later, the plaster is re- dorsal side Follow-up examination was possible with
moved A powerful grip is permitted about 10-12 weeks after 70 patients (Table 3).
the operation The metal plate is removed 6 months after sur- When analyzing the results we must take into con-
gery. sideration subjective complaints, objective function
of the wirst and the hand, and roentgenographic find-
ings Thus we can distinguish four degrees for each
Results
examination point: very good, I; good, II; satisfactry,
III; poor, IV They are characterized by the follow-
During the 7 years from 1981 to 1987 we treated 84
hands of 82 patients in the manner described The ing findings:
operations were carried out 8 weeks-2 years from the
date of the injury (Table 1) The patients ranged in Subjective Complaints
age from 18 to 67 years (Table 2) Forty patients were I No complaints, unhindered use of the hand
male and 42 were female Two of them had to be
operated on both arms In 33 cases the apporach was II Ordinary use of hand and forearm, but com-
made from the volar side and in 51 cases from the plaints with strong effort
III Pain when grabbing, restricted use of the hand
Table 1 Interval between injury and corrective surgery when working
Months n IV Severe pain in the wrist joint continuously and
with each movement
<2 8
2-4 24
RadiographicFindings
4-6 24
7-12 7 I Identical anatomical findings on both sides; re-
12-24 4 construction of the radial base and the wrist joint
>24 3 plane; fully structured bone; no arthritis
Total 70 II Remaining shortening of about 1-2 mm; volar or
dorsal tilt of the joint plane of less than 10
III Shortening of the radioulnar joint up to 3 mm;
Table 2 Age of patients at operation
radial tilt of the joint plane of more than 5; dor-
Age-group n sal or radial tilt of about 10 -20; bony atrophy
<18 2 IV Continuing severe malposition of the tilt of the
18-20 3 joint plane and/or shortening by more than 3 mm;
21-30 11 uncertain bony healing; pseudarthrosis; severe
31-40 15 bony atrophy according to Sudeck
41-50 20
51-60 10 Mobility and Grip Function
> 60 9
I Unlimited mobility of wrist joint; unlimited rota-
Total 70
tion of the forearm; unlimited grip strength
306 M Roesgen and G Hierholzer: Osteotomy of Distal Radius After Fracture

Fig 8 a Vigorimeter used for assessment of grip strength. Analysis of Failures


b Pressure on ball shows grip strength, comparing healthy with
operated hand Five independent measurements are taken In two cases there were complications in the form of
with each patient infections; these healed but left extensive scars,
which caused considerable limitation of mobility and
complete loss of grip In two cases pseudarthrosis
II Deviation of wrist-joint mobility in direction of made a second operation necessary Reosteosynthesis
the former malposition, movement contrary to was done, and the period of illness lasted about 1
the malposition of about 10 ; limitation of forearm year The function of the hand and the grip were con-
rotation outwards and inwards of about 20 , siderably reduced In one case the reconstruction
similar callosity on both sides, grip strength di- failed; the malposition remained The plate and the
minished by about 20 % screws loosened because the patient removed the
plaster by himself and moved his hand too soon.
III Limited mobility in all directions of not more
than one-third; hindered forearm rotation in-
wards and outwards of about 30; limited power Contraindication
of about 40 %; slight callosity This procedure is contraindicated when there is se-
IV Extreme limitation of wrist-joint mobility of vere arthritis of the wrist joint in its radioulnar or
more than 50%; restricted rotation of the radiocarpal part or if there are dislocation in the joint
forearm in one direction by 50% and more; loss surface of the radius In such cases the function of the
of callosity on the palmar surface; any use of the hand and the strength of the grip are severely disor-
hand impossible dered, and we recommend an arthrodesis of the joint.
The patients then lose the rest of their painful and
The power of the hand grip was measured with a Vig- shaky mobility but gain a stronger grip for their fin-
orimeter (Fig 8) Of five independent measurements gers and hand without pain.
the extreme upper and lower results were eliminated;
the average was derived from the remaining three.
With five patients we had diverging data, and from
this we concluded that their use of the grip was un- Discussion
controlled and inadequate The curves produced by
the Vi-gorimeter clearly showed that grip power de- If malposition remains after a radial fracture it should
pends on the patient's will and intention. be recognized as an aesthetic disorder This outward
In 56 of 70 cases, i e , in more than 80%, we appearance indicates a painful disturbance of the
achieved good or excellent results The results in nine wrist motion Regardless of a patient's age, unhin-
patients were satisfactory, but five patients showed dered function of the hands is necessary Normal
poor results with no effect of the operative proce- function can be attained only if the destroyed topo-
dure. graphical situation and the normal anatomy are re-
M Roesgen and G Hierholzer: Osteotomy of Distal Radius After Fracture 307

Fig 9 a Six months after injury and 3 months prior to correc- no point in waiting, because the atrophy will not dis-
tive osteotomy: complete dislocation of radial base to dorsal; appear until the normal anatomy and nearly pain-
radioulnar joint is destroyed and there is contact between ulnar
free mobility are restored.
head and lunate and triquetral bones b Reduction of distal
fragment, insertion of corticocancellous chip and buttress plate The operation can be performed regardless of the
via dorsal approach c One month post-operatively, no gap is patient's age Older people need their upper extrem-
seen between fragments ities more and more for weight bearing to relieve
their lower extremities Our oldest patient was 67
years old Looking at Table 2, we see that 80 % of our
patients between 20 and 60 years were in the 40 to
stored l1, 3, 9, 11l The better the correction, the bet- 50-year age-group Distal radius fracture is typically
ter the results concerning function It is true that a an injury of elderly patients, 60 years and more, but
deviation of the radial joint surface to the dorsal or to we have performed corrective osteotomy mostly on
the volar side does not reduce the wrist mobility so younger people, though we apply the same procedure
severely But there is a severe reduction if, in addi- to elderly patients as well There are more male pa-
tion to this, we find a deviation to the radial side or a tients than would be expected, considering that the
shortening of the radius, or both l3, 6 l. typical radial fracture patient is an elderly woman.
In these cases the interaction of the extensor and From this we conclude that younger people and work-
flexor tendons is disturbed Their directions are bent, ing men want to have the unlimited use of their hand
the capsule is stretched out, and direct contact be- restored and expect a good result with this operation.
tween the ulnar head and the proximal carpal bone Most patients were operated on within 6 months
has taken place l4, 8 l (Fig 9) This causes complaints after their injury This means that the malposition
and is indication for a corrective operation By a cor- was recognized early and the corrective operation
rective osteotomy it is also possible to stop the bony was done before the patient had been able to use the
atrophy according to Sudeck The signs of Sudeck's hand very much The longer the interval between the
atrophy are diminished calcification in comparison accident and the corrective osteotomy, the more pain
with the normal hand and spots of decalcified bone the patients suffered.
ranging from the size of a pinhead to that of a bean, To evaluate the results we must compare them
which are located in the base of the radial bone distal first with the situation of the normal, uninjured hand
to the fracture, in the carpal bones, and in the meta- and second with that of the injured hand before sur-
carpal bones In the course of further healing the gery; in most cases the injured hand was completely
bony signs disappear Moreover, we find stripes of unstable In 65 of the 70 patients we have followed up
decalcification with distinctly outlined bony trabeculae. the resutl was improvement by at least one level;
These are symptoms of a general atrophy which is 50 % of the patients improved by two levels, three pa-
caused by the long-lasting immobilization in a plaster tients even by three levels For only five patients with
cast and the following inactivity. the lowest level of healing was there no improvement
Correcting the anatomical situation means inter- compared with the situation before the operation In
rupting the vicious circle of pain, swelling, decrease no case was the postoperative result worse Patients
of blood supply, and stiffness With patients who suf- at level III before the operation were always im-
fer from Sudeck's atrophy we perform the corrective proved, but there were none at levels II or I pre-
operation directly and as early as possible There is operatively.
308 M Roesgen and G Hierholzer: Osteotomy of Distal Radius After Fracture

In any case a corrective operation is more exten- 3 Fernandez DL (1982) Correction of post-traumatic wrist
sive and the period of disability is longer for a distal deformity in adults by osteotomy, bone-grafting and inter-
nal fixation J Bone Joint Surg lAml 64:1164-1178
radius fracture than for a simple radial fracture Suc-
4 Kohler R, Walch G, Noyer D, Chappuis JP (1982) Main
cess lies in to what degree the patient is able to use bote post-traumatique Problemes therdpeutiques (propos
his hand, in the grip strength, in how extensively he de 5 cas) Rev Chir Orthop 68:333-342
can move his wrist joint, and in the fact that he can do 5 Lanz U, Kron W (1976) Neue Technik zur Korrektur in
this without pain Thus, success means improvement Fehlstellung verheilter distaler Radiusfrakturen Hand-
chirurgie 8:203
in quality of life, and 80 % of the operations are suc-
6 Linscheid RL, Dobyns JH, Beabout JW, Bryan RS (1972)
cessful The fact that this operation requires much Traumatic instability of the wrist Diagnosis, classification
time and energy and carries some risks is balanced by and pathomechanics J Bone Joint Surg lAml 54:1612
the advantage that it prevents possible early arthrosis 7 Melone CP (1984) Articular fractures of the distal radius.
of the wrist joint. Orthop Clin North Am 15:217-236
8 Mino DE, Palmer AK, Levinsohn EM (1985) Radiography
and computerized tomography in the diagnosis of incon-
gruity of the distal radio-ulnar joint J Bone Joint Surg
lAml 67:247
9 Miiller-Farber J, Griebel W (1979) Der sekundare Kor-
References rektureingriff am distalen Radius bei posttraumatischer
Fehlstellung Unfallheilkunde 82:23
10 Newmeyer WL, Green DP (1982) Rupture of digital exten-
1 Cotta H (1980) Die Indikation und Technik der Korrek- sor tendons following distal ulna resection J Bone Joint
tureingriffe nach Briichen am distalen Unterarm Unfall- Surg lAml 64:178-181
heilkd 148:106 11 Scholder P (1976) L'osteotomie de raccourcissement du
2 Ehalt W (1935) Die Bruchformen am unteren Ende der cubitus dans les S6 quelles de fracture de Pouteau-Colles Z
Elle und Speiche Arch Orthop Unfall-Chir 35:397 Unfallmed Berufskr 69:177-181