 Operative
treatment consisted of exposure through a volar Henry approach. The
ununited fracture was realigned using a distractor. The distal ulna
was resected. The synovial nonunion was debrided and the resulting
defect packed with autogenous cancellous bone from the distal ulna
that was resected. Fixation was achieved in two planes using a 2.7
mm condylar blade plate applied to the radial surface of the distal
radius and a 2.7 mm T-shaped plate applied to the volar surface of
the distal radius.
Figure 3: The nonunion is fixed
and the distal ulna resected.
Two years later, the fracture is healed, and function has been
restored. Wrist flexion and extension were each 40 degrees, supination
was 60 degres and pronation 80 degrees. Grip strength is 50% of
the opposite side.
Figure 4 A and B: Followup at two
years.
Discussion:
Failure of a distal radius to heal is either becoming more common
or is now more commonly identified and discussed. Recent publications
regarding ununited fractures of the distal radius recommend treatment
with total wrist arthrodesis. The most challenging cases are those
in which the patient has developed a synovial nonunion. Synovial nonunion
further erodes the distal fragment and contributes to stiffness of
the wrist capsule as all motion occurs through the fracture itself.
The case described demonstrates that it is possible to heal the
fracture and maintain wrist mobility even in the presence of a synovial
nonunion resulting in a small distal fragment. Techniques which
have proved useful included the use of fixed-angle devices such
as the condylar blade plate as well as the use of two fixation devices
oriented at 90 degrees to one another. Fixed-angle devices do not
depend upon thread-bone purchase for stability and are may gain
better hold in osteopenic metaphyseal bone. Fixation in orthogonal
planes is a recognized technique for increasing the strength of
a construct and can be accomplished without excessively devitalizing
the bone. |
