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J Wrist Surg 2014; 03(03): 181-186
DOI: 10.1055/s-0034-1384747
Scientific Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Ulnar Shortening Osteotomy for Distal Radius Malunion

Robin N. Kamal
1   Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
,
Fraser J. Leversedge
1   Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
› Author Affiliations
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Publication History

Publication Date:
31 July 2014 (online)

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Abstract

Background Malunion is a common complication of distal radius fractures. Ulnar shortening osteotomy (USO) may be an effective treatment for distal radius malunion when appropriate indications are observed.

Methods The use of USO for treatment of distal radius fracture malunion is described for older patients (typically patients >50 years) with dorsal or volar tilt less than 20 degrees and no carpal malalignment or intercarpal or distal radioulnar joint (DRUJ) arthritis.

Description of Technique Preoperative radiographs are examined to ensure there are no contraindications to ulnar shortening osteotomy. The neutral posteroanterior (PA) radiograph is used to measure ulnar variance and to estimate the amount of ulnar shortening required. An ulnar, mid-sagittal incision is used and the dorsal sensory branch of the ulnar nerve is preserved. An USO-specific plating system with cutting jig is used to create parallel oblique osteotomies to facilitate shortening. Intraoperative fluoroscopy and clinical range of motion are checked to ensure adequate shortening and congruous reduction of the ulnar head within the sigmoid notch.

Results Previous outcomes evaluation of USO has demonstrated improvement in functional activities, including average flexion-extension and pronosupination motions, and patient reported outcomes.

Conclusion The concept and technique of USO are reviewed for the treatment of distal radius malunion when specific indications are observed. Careful attention to detail related to surgical indications and to surgical technique typically will improve range of motion, pain scores, and patient-reported outcomes and will reduce the inherent risks of the procedure, such as ulnar nonunion or the symptoms related to unrecognized joint arthritis.

Level of Evidence: Level IV

Keywords

distal radius fracture - malunion - ulnar shortening osteotomy - ulnar wrist pain - ulnar abutment
 

  • References

  • 1 Milch H. So-called dislocation of the lower end of the ulna. Ann Surg 1942; 116 (2) 282-292
    CrossrefPubMedSearch in Google Scholar
  • 2 Yin HW, Qiu YQ, Shen YD, Xu JG, Gu YD, Xu WD. Arthroscopic distal metaphyseal ulnar shortening osteotomy for ulnar impaction syndrome: a different technique. J Hand Surg Am 2013; 38 (11) 2257-2262
    CrossrefPubMedSearch in Google Scholar
  • 3 Cha SM, Shin HD, Kim KC, Park E. Ulnar shortening for adolescent ulnar impaction syndrome: radiological and clinical outcomes. J Hand Surg Am 2012; 37 (12) 2462-2467
    CrossrefPubMedSearch in Google Scholar
  • 4 McBeath R, Katolik LI, Shin EK. Ulnar shortening osteotomy for ulnar impaction syndrome. J Hand Surg Am 2013; 38 (2) 379-381
    CrossrefPubMedSearch in Google Scholar
  • 5 Lee JI, Suh DH, Byun JS , et al. Radiographic appearance and patient outcome after ulnar shortening osteotomy for idiopathic ulnar impaction syndrome. J Hand Surg Am 2012; 37 (5) 975-981
    CrossrefPubMedSearch in Google Scholar
  • 6 Fricker R, Pfeiffer KM, Troeger H. Ulnar shortening osteotomy in posttraumatic ulnar impaction syndrome. Arch Orthop Trauma Surg 1996; 115 (3-4) 158-161
    CrossrefPubMedSearch in Google Scholar
  • 7 Srinivasan RC, Jain D, Richard MJ, Leversedge FJ, Mithani SK, Ruch DS. Isolated ulnar shortening osteotomy for the treatment of extra-articular distal radius malunion. J Hand Surg Am 2013; 38 (6) 1106-1110
    CrossrefPubMedSearch in Google Scholar
  • 8 Tatebe M, Shinohara T, Okui N, Yamamoto M, Imaeda T, Hirata H. Results of ulnar shortening osteotomy for ulnocarpal abutment after malunited distal radius fracture. Acta Orthop Belg 2012; 78 (6) 714-718
    PubMedSearch in Google Scholar
  • 9 Oskam J, Bongers KM, Karthaus AJ, Frima AJ, Klasen HJ. Corrective osteotomy for malunion of the distal radius: the effect of concomitant ulnar shortening osteotomy. Arch Orthop Trauma Surg 1996; 115 (3-4) 219-222
    CrossrefPubMedSearch in Google Scholar
  • 10 Oskam J, Kingma J, Klasen HJ. Ulnar-shortening osteotomy after fracture of the distal radius. Arch Orthop Trauma Surg 1993; 112 (4) 198-200
    CrossrefPubMedSearch in Google Scholar
  • 11 af Ekenstam F, Hagert CG. Anatomical studies on the geometry and stability of the distal radio ulnar joint. Scand J Plast Reconstr Surg 1985; 19 (1) 17-25
    CrossrefPubMedSearch in Google Scholar
  • 12 af Ekenstam FW, Palmer AK, Glisson RR. The load on the radius and ulna in different positions of the wrist and forearm. A cadaver study. Acta Orthop Scand 1984; 55 (3) 363-365
    CrossrefPubMedSearch in Google Scholar
  • 13 Tolat AR, Stanley JK, Trail IA. A cadaveric study of the anatomy and stability of the distal radioulnar joint in the coronal and transverse planes. J Hand Surg [Br] 1996; 21 (5) 587-594
    CrossrefPubMedSearch in Google Scholar
  • 14 Kleinman WB. Stability of the distal radioulna joint: biomechanics, pathophysiology, physical diagnosis, and restoration of function: what we have learned in 25 years. J Hand Surg Am 2007; 32 (7) 1086-1106
    CrossrefPubMedSearch in Google Scholar
  • 15 Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist—anatomy and function. J Hand Surg Am 1981; 6 (2) 153-162
    CrossrefPubMedSearch in Google Scholar
  • 16 Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg [Br] 1996; 21 (5) 581-586
    CrossrefPubMedSearch in Google Scholar
  • 17 Freedman DM, Edwards Jr GS, Willems MJ, Meals RA. Right versus left symmetry of ulnar variance. A radiographic assessment. Clin Orthop Relat Res 1998; (354) 153-158
    PubMedSearch in Google Scholar
  • 18 Jung JM, Baek GH, Kim JH, Lee YH, Chung MS. Changes in ulnar variance in relation to forearm rotation and grip. J Bone Joint Surg Br 2001; 83 (7) 1029-1033
    CrossrefPubMedSearch in Google Scholar
  • 19 Constantine KJ, Tomaino MM, Herndon JH, Sotereanos DG. Comparison of ulnar shortening osteotomy and the wafer resection procedure as treatment for ulnar impaction syndrome. J Hand Surg Am 2000; 25 (1) 55-60
    CrossrefPubMedSearch in Google Scholar
  • 20 Pogue DJ, Viegas SF, Patterson RM , et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg Am 1990; 15 (5) 721-727
    CrossrefPubMedSearch in Google Scholar
  • 21 Slagel BE, Luenam S, Pichora DR. Management of post-traumatic malunion of fractures of the distal radius. Hand Clin 2010; 26 (1) 71-84
    CrossrefPubMedSearch in Google Scholar
  • 22 Slagel BE, Luenam S, Pichora DR. Management of post-traumatic malunion of fractures of the distal radius. Orthop Clin North Am 2007; 38 (2) 203-216 , vi vi.
    CrossrefPubMedSearch in Google Scholar
  • 23 Prommersberger KJ, Froehner SC, Schmitt RR, Lanz UB. Rotational deformity in malunited fractures of the distal radius. J Hand Surg Am 2004; 29 (1) 110-115
    CrossrefPubMedSearch in Google Scholar
  • 24 Bushnell BD, Bynum DK. Malunion of the distal radius. J Am Acad Orthop Surg 2007; 15 (1) 27-40
    CrossrefPubMedSearch in Google Scholar
  • 25 Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg 2005; 13 (3) 159-171
    PubMedSearch in Google Scholar
  • 26 Graham TJ. Surgical correction of malunited fractures of the distal radius. J Am Acad Orthop Surg 1997; 5 (5) 270-281
    CrossrefPubMedSearch in Google Scholar
  • 27 Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res 1984; (187) 26-35
    PubMedSearch in Google Scholar
  • 28 Markolf KL, Tejwani SG, Benhaim P. Effects of wafer resection and hemiresection from the distal ulna on load-sharing at the wrist: a cadaveric study. J Hand Surg Am 2005; 30 (2) 351-358
    CrossrefPubMedSearch in Google Scholar
  • 29 Adams BD. Effects of radial deformity on distal radioulnar joint mechanics. J Hand Surg Am 1993; 18 (3) 492-498
    CrossrefPubMedSearch in Google Scholar
  • 30 Bell MJ, Hill RJ, McMurtry RY. Ulnar impingement syndrome. J Bone Joint Surg Br 1985; 67 (1) 126-129
    PubMedSearch in Google Scholar
  • 31 Bronstein AJ, Trumble TE, Tencer AF. The effects of distal radius fracture malalignment on forearm rotation: a cadaveric study. J Hand Surg Am 1997; 22 (2) 258-262
    PubMedSearch in Google Scholar
  • 32 Hollingsworth R, Morris J. The importance of the ulnar side of the wrist in fractures of the distal end of the radius. Injury 1976; 7 (4) 263-266
    PubMedSearch in Google Scholar
  • 33 Werner FW, Palmer AK, Fortino MD, Short WH. Force transmission through the distal ulna: effect of ulnar variance, lunate fossa angulation, and radial and palmar tilt of the distal radius. J Hand Surg Am 1992; 17 (3) 423-428
    CrossrefPubMedSearch in Google Scholar
  • 34 Hirahara H, Neale PG, Lin YT, Cooney WP, An KN. Kinematic and torque-related effects of dorsally angulated distal radius fractures and the distal radial ulnar joint. J Hand Surg Am 2003; 28 (4) 614-621
    CrossrefPubMedSearch in Google Scholar
  • 35 Nishiwaki M, Nakamura T, Nagura T, Toyama Y, Ikegami H. Ulnar-shortening effect on distal radioulnar joint pressure: a biomechanical study. J Hand Surg Am 2008; 33 (2) 198-205
    CrossrefPubMedSearch in Google Scholar
  • 36 Friedman SL, Palmer AK. The ulnar impaction syndrome. Hand Clin 1991; 7 (2) 295-310
    PubMedSearch in Google Scholar
  • 37 Chun S, Palmer AK. The ulnar impaction syndrome: follow-up of ulnar shortening osteotomy. J Hand Surg Am 1993; 18 (1) 46-53
    CrossrefPubMedSearch in Google Scholar
  • 38 Loh YC, Van Den Abbeele K, Stanley JK, Trail IA. The results of ulnar shortening for ulnar impaction syndrome. J Hand Surg [Br] 1999; 24 (3) 316-320
    CrossrefPubMedSearch in Google Scholar
  • 39 Hollevoet N, Verdonk R. The functional importance of malunion in distal radius fractures. Acta Orthop Belg 2003; 69 (3) 239-245
    PubMedSearch in Google Scholar
  • 40 Batra S, Gupta A. The effect of fracture-related factors on the functional outcome at 1.  year in distal radius fractures. Injury 2002; 33 (6) 499-502
    CrossrefPubMedSearch in Google Scholar
  • 41 Bickerstaff DR, Bell MJ. Carpal malalignment in Colles' fractures. J Hand Surg [Br] 1989; 14 (2) 155-160
    PubMedSearch in Google Scholar
  • 42 Porter M, Stockley I. Fractures of the distal radius. Intermediate and end results in relation to radiologic parameters. Clin Orthop Relat Res 1987; (220) 241-252
    PubMedSearch in Google Scholar
  • 43 Solgaard S. Function after distal radius fracture. Acta Orthop Scand 1988; 59 (1) 39-42
    CrossrefPubMedSearch in Google Scholar
  • 44 Nishiwaki M, Nakamura T, Nakao Y, Nagura T, Toyama Y. Ulnar shortening effect on distal radioulnar joint stability: a biomechanical study. J Hand Surg Am 2005; 30 (4) 719-726
    CrossrefPubMedSearch in Google Scholar
  • 45 Darrow Jr JC, Linscheid RL, Dobyns JH, Mann III JM, Wood MB, Beckenbaugh RD. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg Am 1985; 10 (4) 482-491
    CrossrefPubMedSearch in Google Scholar
  • 46 Minami A, Kato H. Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance. J Hand Surg Am 1998; 23 (5) 904-908
    CrossrefPubMedSearch in Google Scholar
  • 47 Darlis NA, Ferraz IC, Kaufmann RW, Sotereanos DG. Step-cut distal ulnar-shortening osteotomy. J Hand Surg Am 2005; 30 (5) 943-948
    CrossrefPubMedSearch in Google Scholar
  • 48 Rayhack JM, Gasser SI, Latta LL, Ouellette EA, Milne EL. Precision oblique osteotomy for shortening of the ulna. J Hand Surg Am 1993; 18 (5) 908-918
    CrossrefPubMedSearch in Google Scholar
  • 49 Greenberg JA, Werner FW, Smith JM. Biomechanical analysis of the distal metaphyseal ulnar shortening osteotomy. J Hand Surg Am 2013; 38 (10) 1919-1924
    CrossrefPubMedSearch in Google Scholar
  • 50 Martin DEZD, Russo SA, Kozin SH. Comparison of compression screw and perpendicular clamp in ulnar shortening osteotomy. American Academy of Orthopaedic Surgeons Annual Meeting. 2014
    PubMedSearch in Google Scholar