SURGICAL TREATMENT OF IMPROPERLY CONSOLIDATED FRACTURES OF DISTAL METAEPIPHYSIS OF THE RADIAL BONE
Podgorbunsky City Clinical Hospital #3,
Kemerovo State Medical Academy,
Department of Public Health of Kemerovo region,
Gorbunova City Clinical Hospital #1, Kemerovo, Russia
One of the most common complications after conservative treatment for fractures of the distal metaepiphysis of the radial bone is non-correct union of fragments (up to 89 %) [1]. It results in disordered extremities length ratio and deforming arthrosis. Angle and rotation displacements of such fractures are complicated by pain syndrome, decreasing range of motion in the radiocarpal joint and decreasing grip strength and hand function [2, 3, 4].
The problem can be solved by means of reconstruction of the distal metaepiphysis of the radial bone with use of correcting osteotomy with replacement of bone defect and internal osteosynthesis with angle stability plates [2-6].
Objective – to estimate the results of surgical treatment in patients with improperly consolidated fractures of the distal metaepiphysis of the radial bone.
MATERIALS AND METHODS
We observed 72 patients with improper union of fractures of the distal metaepiphysis of the radial bone. Surgical interventions were performed by means of correcting osteotomy. There were 40 women and 32 men, mean age of 50 (16-80). The time intervals from an injury to surgery were from 6 weeks till 4 months.
The indications for surgery were pain syndrome, deformation, limited motions, decreasing strength and grip of the hand. The radiologic indications for surgery were shortening length of the radial bone (more than 5 mm), more than 2 mm displacement of fragments relating to joint surface of the radial bone, displacement of inclination of articular surface of the radial bone towards the dorsal surface (more than 20 degrees). The contraindications were deforming arthrosis in the radiocarpal joint and manifestations of osteoporosis.
After surgery all patients were examined by means of radiology for both hand joints in two planes. In some cases computer tomography was conducted for confirming the diagnosis (for estimation of osteotomy level), as well as ultrasonic dopplerography for forearm vessels, and electromyography for median and ulnar nerves.
Surgical interventions were performed with tourniquet, anesthesia – by means of intravenous sedation and regional anesthesia according to Sokolovsky V.S.
Surgical treatment was conducted for all patients. It included correcting osteotomy of the radial bone, open reposition, bone plastic procedures and stabilization with T-shaped angle stability plate. Palmar approach was used for 46 patients, dorsal one – for 26. Radial bone defects were replaced by Chronos in 40 patients, autografts from iliac wing – in 32 patients. Also we calculated time intervals for harvesting an autograft from the iliac wing.
Surgical technique
Volar approach
A surgical incision about 8 cm was made on the palmar surface of the distal one-third of the forearm. S-shape or straight shape of an incision is necessary for comfortable approach to articular surfaces. For prevention of injuries to the palmar skin branch of the median nerve we opened the membrane of the tendon of flexor carpi radialis, antebrachial fascia along the external edge of the tendon. The median nerve and the flexor tendons of the fingers 2-5 and palmaris longus were moved towards ulnar direction. The long flexor of the thumb and the tendon of radial flexor of the hand were moved towards radial direction. The next stage was exposure of quadrate pronator muscle. For preventing an injury to the interosseous nerve L-shaped incision was made over the radial border of quadrate pronator muscle.
Osteotomy was conducted at the place of improper union. Reposition in osteotomy site was simplified by dorsal placing an elevator for simplification of manipulations with a distal fragment. Fragmental reposition by the operating surgeon is favored by ligamentotaxis with hand traction, which is performed by the surgeon’s assistant. The graft was placed into the defect. Chronos was used for replacement of the bone defect of wedge shaped in the metaphyseal region of the radial bone. Pins were used for temporary fixation of the fragments. The palmar plate was fixed on the central oval foramen for possibility of moving the plate in different directions. The locked screws in the distal part of the plate with multidirectional angles allow fixation of the distal bone fragment at maximal nearest distance from the joint. The distal fragment was fixed through the central foramen with use of the smooth screw. The screws were used for fixation of the ulnar complex, the radial complex and the median complex. An assistant realizes continuous hand traction for maintaining the anatomic reposition of bone fragments. The final stage of osteosynthesis was placement of the screws in the proximal holes of the plate and removal of a pin. Radiologic control with the electronic optical transducer was realized in frontal and lateral views at each stage of osteosynthesis. After placement of the plates the integrity of the square pronator was restored by means of its suturing to the brachioradial muscle. It prevents direct contact between the plate with screws and flexor tendons of the fingers.
After removal of the pneumatic cuff we conducted hemostasis by means of electrocoagulation. Postsurgical wound draining was realized with silicone fluted drain, which was removed 1-2 days after surgery. The wound was sutured layer-by-layer. On the third day the extremity was fixed with plaster splint from the metacarpophalangeal joints to the border of proximal and middle one-third with physiological position of the radiocarpal joint for decreasing postsurgical pain syndrome.
After medical correction 6 patients with complex regional pain syndrome (CRPS) still suffered from median nerve neuropathy. In such cases neurolysis of the median nerve with extension of palmar approach and transition to the hand was conducted.
The carpal canal exposure with separation of the median nerve and its revision was realized. All cases were accompanied by compression of the median nerve with decrease in its diameter and cyanotic color along the carpal ligament. Microsurgical neurolysis was performed in the region of compression with use of microsurgical technique and optical magnification. Normalization of the color of the nerve was observed in all cases during surgery. After neurolysis of the median nerve we marked the place of the malunion of distal metaepiphysis of the radial bone and performed correction osteotomy according to the above mentioned technique.
Dorsal approach
Along the dorsal surface of the distal one-third of the forearm an incision about 8 cm was made. For preventing an injury, the tendon of the long extensor of the first finger was separated and abducted with use of a holder. Then we identified the region of malunion of the fracture and performed lateral abduction of the tendons of the radial extensors of the hand and medial abduction of the tendons of finger extensors. Osteotomy was conducted, as well as mobilizing the fragments and their reposition with restoring anatomy of the distal metaepiphysis of the radial bone with the external fixation device. The graft was placed into the bone defect. Osteosynthesis of the radial bone was conducted with T-shaped angle stability plate. The external fixation device was dismounted.
The surgery stages were controlled by means of the electronic optical transducer. Hemostasis was conducted with electric coagulation. The wound was drained and sutured by layers. The draining device was removed two days after surgery.
On the third day after surgery the plaster splint was applied along the anterior surface from the proximal one-third of the forearm to the metacarpophalangeal joints in the fingers 2-5 with consideration of the physiologic position.
Postsurgical treatment
The patients received antibiotics and non-steroidal anti-inflammatory drugs during 5 days in the postsurgical period. Complex regional pain syndrome was prevented with vitamin C (500 mg) [7] and the antioxidant for suppressing the immune response to the injury [7, 8].
The patients with osteoporosis received Ca and vitamin D3, electrophoresis with hydrocortisone in the region of the radiocarpal joint and magnetic therapy.
In the postsurgical period the daily sessions of remedial gymnastics under control of the recreation therapist were carried out. Active and passive exercises for the fingers were initiated on the next day after surgery. The plaster splint was removed three days later. Then development of motions in the radiocarpal joint was initiated.
The stable fixation and early development of motions in the hand joint was the main principled approach in rehabilitation treatment of malunion fractures of the distal metaepiphysis of the radial bone.
The results of radiologic study within 1, 2 and 6 months after surgical intervention were estimated according to the following criteria:
1) The degree of union of the fracture;
2) Presence of some signs of deforming arthrosis of the radiocarpal joint;
3) Decreasing height of the distal metaepiphysis of the radial bone ≥ 5 mm;
4) Changes in the radioulnar angle;
5) Changes in the declination angle in sagittal plane of the radial bone.
The results were estimated with the questionnaire of dysfunction of forearm and hand, which is based on the adapted questionnaire DASH [9] and SF-36 [10].
Microsoft Office Excel 2003 was used for creation of the archive database and data summary sheets (the license agreement 74017-640-0000106-57177). The tables were used for visualization of the materials.
Statistica 6.1 software was used for statistical analysis (the license agreement BXXR006B092218FAN11).
The study was based on the sufficient volume of observations and it presents the statistically significant results.
The qualitative signs are presented as absolute values and relative frequency (%).
The relationships between the quantitative signs were examined with Spearman correlation test (R). The relationship was statistically significant if the level of significance was 0.05.
RESULTS
The results of treatment were examined in 65 patients (up to 6 months). According to the questionnaire of dysfunction of forearm and hand, the functional capability of the hand was associated with high quality of life 6-8 weeks after surgery. First of all, mental health restored, as well as emotional state and social activity. The full volume of motions in the hand joint was observed 6 months after surgery. During that period the full union was found at the level of osteotomy with formation of callus (closure of 4 cortical plates) according to the data of radiography in two planes. 3 cases were associated with some signs of deforming arthrosis in the wrist joint. Ultrasound dopplerography showed normalizing and full restoration of perfusion velocity in the injured extremity one month after surgery. Electromyography did not find any events of neuropathy of the median nerve in the examined patients.
In comparison with the bone graft from the iliac wing the use of the bone substitute Chronos for replacement of defects in the radial bone along with correcting osteotomy and internal osteosynthesis with angle stability T-shaped plate allows reducing duration of surgery by 34 ± 1.6 minutes (or 40.5 % ± 4.7), reduction of traumatizing the patient and preventing additional anesthesia and possible injuries in donor region of vessels and nerves, prevention of bone defects, earlier restoration of emotional state, full removal of pain syndrome and restoration of functional capability of the hand and the forearm. The terms are 1-2 months after surgical treatment in comparison with 2-6 months in the comparison group.
During the postsurgical period two patients demonstrated some infectious complications, which were corrected two weeks after surgery. The complications did not influence on the final results of treatment. According to electromyography 3 patients demonstrated median nerve neuropathy, pain syndrome and numbness of the fingers 1-3, events of axon degeneration and denervation syndrome. Correction of pain syndrome, neurostimulating therapy (proserin, vitamins of B group), drugs for stimulating blood circulation (rheopolyglucinum, trental) removed the clinical symptoms of the median nerve in all patients within two months.
The above mentioned measures of examination were used for 65 patients and showed the excellent results in 47 (72.5 %), good results in 11 (17.5 %) and satisfactory ones in 7 (10 %) patients.
DISCUSSION
Malunion is one of the most common complications after fractures of the distal metaepiphysis of the radial bone [2, 11]. Joint incongruence is one of unfavorable factors of functional outcomes of treatment. Development of the advanced visualizing methods (for example, three-dimensional reconstruction for CT) and angle stability fixators promoted the interest to surgical correction of malunion fractures of the distal metaepiphysis of the radial bone.
The important factor for positive results of treatment is timing of correcting osteotomy. Some authors [12] consider that realization of early osteotomy (after 8 weeks on average) is more practicable and it allows reducing pain syndrome and optimizing the hand function. According to our data, the results of early (8 weeks) and late reconstruction of malunion fractures are comparable.
According to the literature data the palmar approach is used in most cases of surgical care [4]. We used the palmar approach for 46 patients with malunion and palmar subluxation. We think that such approach simplifies correcting osteotomy and estimation of size of a defect in the radial bone (estimation for defect replacement). If some clinical symptoms of median nerve neuropathy are present, it simplifies revision and neurolysis.
The issue of replacement of radial bone defects is equally important. The autograft from the iliac wing is associated with some complications: pain syndrome, lateral femoral nerve injury, infection and others [13].
Therefore, according to our opinion, the alternative technique is bone substitutes, which prevent complications and reduce time of surgery.
CONCLUSION
The main causes of malunion of the distal metaepiphysis of the radial bone after conservative treatment is absence of closed reposition, non-reduced type of the fracture, secondary displacement of bone fragments, especially in old patients with low mineral density of the radial bone.
Correcting osteotomy and use of the angle stability system for malunion fractures of the distal metaepiphysis of the radial bone allow precise restoration of anatomy, creation of stable fixation of bone fragments, prevention of secondary displacement and realization of early treatment even in presence of osteoporosis events.
Use of Chronos bone substitute for replacement of radial bone defects allows prevention of possible complications, reduction of surgery time and provides higher quality of life of patients.
Clinical case #1
The patient P., age of 40, a craftsman. He suffered from an industrial injury to the right forearm. The patient received conservative treatment (closed reposition) and plaster immobilization. 6 weeks later the control radiologic study identified the malunion fracture in the distal region of the radial bone. Radiography (Fig. 1a) and computer tomography (Fig. 2a) were conducted. The operation was conducted: correcting osteotomy, stabilization with LCP 22.4 mm, defect replacement with use of Chronos. 5 weeks later the union of the fracture was noted, the radioulnar joint and the length of the radial bone were restored (Fig. 1b, 2b).
Figure 1
The X-ray image of the patient P., age of 40: a – before surgery (frontal and lateral views); b – after surgery (frontal and lateral views)
a 
b
Figure 2
CT images of the patient P., age of 40: a – before surgery (frontal and lateral views); b – after surgery (frontal and lateral views)
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b
The clinical case #2
The patient, age of 46, suffered from an injury: the closed fracture of the distal department of the radial bone. She received conservative treatment (reposition and plaster splint). The control examination found the malunion of the distal part of the radial bone. The radiologic (Fig. 3a) and computer tomographic (Fig. 4a) examinations were conducted. The surgery was conducted: osteotomy, fixation with LCP 2.4 mm and the plate for radial defect Chronos. The fracture union was noted after 6 weeks. The control X-ray images, CT (Fig. 3b, 4b) images were collected. The length of the radial bone and the radioulnar correspondence were restored.
Figure 3
The X-ray image of the patient T., age of 46: a – before surgery (frontal and lateral views); b – after surgery (frontal and lateral views)
a 
b
Figure 4
CT images of the patient T., age of 46: a – before surgery (frontal and lateral views); b – after surgery (frontal and lateral views)
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b