Journal List > Arch Hand Microsurg > v.24(2) > 1125363

Shim and Park: Surgical Treatment for Malunited Radius Fracture with Distal Radioulnar Joint Instability

초록

Purpose:

The purpose of this study is to report the results of surgical treatment for malunited radius shaft fracture combined with distal radioulnar joint (DRUJ) instability.

Methods:

A retrospective review of patients with malunited radius shaft fracture with DRUJ instability from 2002 to 2015 was performed. All patients underwent corrective osteotomy for malunited radius. Anatomical distal radioulnar ligament reconstruction was additionally performed in patients who had remaining instability after correction. Preoperative and postoperative the anteroposterior stress test, range of motion, pain visual analogue scale, grip strength, modified Mayo wrist score, and disabilities of the arm, shoulder and hand score were analyzed.

Results:

A total of 13 patients with an average age of 25 years (range, 15-41 years) were included. The mean follow-up period was 35 months (range, 24-66 months). The DRUJ joint became stable in 4 patients after corrective osteotomy, and thus, no further procedures were required. For 9 patients, additional ligament reconstruction was performed at the same time after osteotomy. DRUJ stability was obtained in 11 patients at the final follow-up. One patient, who failed to achieve DRUJ stability due to insufficient correction, underwent redo-osteotomy. Mild limitation of rotation was observed in 4 patients. Clinical scores were significantly improved after surgery.

Conclusion:

Restoration of DRUJ alignment by osteotomy is mandatory for treatment of malunited radius combined with DRUJ instability. Additional anatomical ligament reconstruction may improve DRUJ stability.

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Fig. 1.
(A) Preoperative wrist posteroanterior and lateral radiographs of a 24-year-old woman showed distal radioulnar joint subluxation associated with radial malunion. (B) Computed tomography showed volar subluxation of the ulna. This patient was treated with osteotomy and distal radioulnar ligament reconstruction. (C) Radiographs obtained one year after the surgery showed restored alignment. Note that the bone tunnels for ligament reconstruction in the distal radius and ulnar head are visible (arrowheads).
ahm-24-103f1.tif
Fig. 2.
(A) Preoperative wrist posteroanterior and lateral radiographs of a 15-year-old man showed distal radioulnar joint (DRUJ) subluxation associated with radial malunion. (B) After one year after surgery, he still had grade 3 instability after corrective osteotomy, and ligament reconstruction failed to restore DRUJ alignment. Corrective osteotomy was performed again. (C) Radiographs obtained one year after re-do osteotomy show improved alignment and stability.
ahm-24-103f2.tif
Table 1.
Grading of the distal radioulnar joint stress test
Grade Definition
0 No difference of laxity (symmetric)
1 Laxity with firm end point
2 Translation with unstable end point
3 Subluxation during rotation
Table 2.
Preoperative data of all cases
Case No. Sex Age (yr) Interval between initial fracture and osteotomy (mo) Preoperative stress test Location of fracture malunion Preoperative degree of angulation
Lateral view (°), direction Antero-posterior (°), direction
1 Male 20 96 Grade 3 Distal shaft 11.9, volar 3.9, varus
2 Male 15 15 Grade 3 Distal shaft 15.3, dorsal 4.5, varus
3 Female 16 42 Grade 3 Mid shaft 10.1, dorsal 12.5, valgus
4 Male 24 120 Grade 3 Mid shaft 17.5, dorsal 10.8, valgus
5 Female 39 312 Grade 3 Distal shaft 12.1, dorsal 8.2, valgus
6 Female 15 21 Grade 2 Distal shaft 18.5, dorsal 0.2, valgus
7 Male 22 132 Grade 2 Distal shaft 4.9, dorsal 6.1, valgus
8 Male 41 300 Grade 2 Distal shaft 9.2, dorsal 1.4, valgus
9 Male 32 10 Grade 2 Distal shaft 10.0, dorsal 4.5, valgus
10 Male 20 120 Grade 3 Distal shaft 10.1, dorsal 1.3, varus
11 Male 23 84 Grade 2 Distal shaft 8.5, dorsal 6.6, valgus
12 Male 19 96 Grade 3 Distal shaft 17.0, dorsal 9.8, valgus
13 Male 40 312 Grade 3 Mid shaft 17.9, dorsal 4.6, valgus
Mean   25 128     12.5 5.7

Grading according to Table 1.

Difference between a malunion site and other, distal fragment displacement direction.

Table 3.
Postoperative outcomes of all cases
Case No. Follow-up (mo) DRUJ ligament reconstruction Postoperative stress test MMWS
Preoperative Postoperative
1 50 Yes Grade 0 20 85
2 66 Yes Grade 3 65 75
3 28 Yes Grade 0 70 85
4 25 Yes Grade 0 50 75
5 25 Yes Grade 1 60 60
6 57 Yes Grade 0 60 60
7 24 No Grade 1 55 85
8 54 No Grade 0 55 95
9 28 Yes Grade 0 50 50
10 26 No Grade 1 85 85
11 28 Yes Grade 0 75 90
12 26 Yes Grade 0 70 90
13 24 No Grade 2 60 70
Mean 35     60 77

DRUJ: distal radioulnar joint, MMWS: modified Mayo wrist score.

Grading according to Table 1.

Redo osteotomy.

Table 4.
Pre- and postoperative clinical outcomes
Variable pVAS Grip strength (lb) MMWS DASH score
Total        
 Preoperative 5.4±2.0 57.6±23.1 59.6±15.6 37.9±17.8
 Postoperative 2.2±1.6 72.3±20.6 77.3±13.7 21.2±19.8
 p-value <0.001 0.021 0.006 <0.001
LR        
 Preoperative 5.3±1.7 48.8±19.0 57.7±16.6 42.8±18.1
 Postoperative 2.6±1.7 65.5±20.2 74.4±14.6 26.1±22.1
 p-value 0.011 0.041 0.027 0.011
CO        
 Preoperative 5.5±2.9 77.5±20.6 63.7±14.3 26.8±12.5
 Postoperative 1.3±0.5 87.5±13.2 83.7±10.3 10.2±5.2
 p-value 0.077 0.109 0.109 0.068

Values are presented as mean±standard deviation.

pVAS: pain visual analogue scale, MMWS: modified Mayo wrist score, DASH: disabilities of the arm, shoulder and hand.

Additional ligament reconstruction group,

corrective osteotomy only group.

Table 5.
Pre- and postoperative range of motion
Variable Range of motion (°)
Extension Flexion Supination Pronation
Preoperative 78.8±7.6 76.5±10.2 82.3±8.5 73.0±20.8
Postoperative 77.6±11.4 74.6±13.4 78.4±8.7 75.7±12.8
p-value 0.703 0.488 0.268 0.383

Values are presented as mean±standard deviation.

Table 6.
Pre- and postoperative radiographic data
Variable Lateral view (°) Antero-posterior (°) Ulnar variance (mm)
Preoperative 12.5±4.3 5.7±3.8 0±1.6
Postoperative 4.3±4.6 3.2±2.2 0.9±2.0
p-value 0.001 0.045 0.220

Values are presented as mean±standard deviation.

Difference between a malunion site and other.

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