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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 22-26

Posttraumatic distal radius growth arrest treatment by ilizarov distraction osteogenesis


Department of Orthopedic Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Web Publication23-Aug-2019

Correspondence Address:
Dr. Abdullah A Nada
Faculty of Medicine, Tanta University, Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_21_18

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  Abstract 

Background: Posttraumatic distal radius growth arrest is a challenging orthopedic condition, due to a combination of several deformity components including shortening, angulation and joint line malorientation. It can drastically affect both the function and the shape of the wrist and forearm. However, little has been written about this problem. Patients and Methods: In this retrospective study, seven adolescent patients were operated in our department. All had posttraumatic distal radius growth arrest that resulted in shortening with or without angular deformity. The management consisted of distal radius metaphyseal osteotomy and distraction osteogenesis using Ilizarov frame. The patients' ages ranged from 12 to 15 years. The mean shortening of the radius was 2.2 cm. Correction was assessed radiologically (radial length, joint orientation line) and clinically by Mayo Wrist Score. Results: The mean external fixation time was 2.4 months (range from 2 to 3 months). The mean total treatment time was 12.3 weeks (range from 12 to 16 weeks). The mean bone healing index was 1.13 months/cm. The Mayo Wrist Score mean was 85.7 (range: 75–95) points. According to the Mayo Wrist Score, results were excellent in three patients, good in three patients, satisfactory in one patient with no unsatisfactory results. Superficial pin tract infection occurred in all cases and was managed without further sequelae. Conclusion: Distraction osteogenesis, by Ilizarov external fixator, addresses the sequelae of posttraumatic distal radius growth arrest by restoring the normal anatomy in a controlled biological manner, without further grafting procedures through a minimally invasive approach.

Keywords: Distal radius, distraction osteogenesis, growth arrest, Ilizarov, lengthening


How to cite this article:
El-Rosasy MA, Nada AA, Romeih M. Posttraumatic distal radius growth arrest treatment by ilizarov distraction osteogenesis. J Limb Lengthen Reconstr 2019;5:22-6

How to cite this URL:
El-Rosasy MA, Nada AA, Romeih M. Posttraumatic distal radius growth arrest treatment by ilizarov distraction osteogenesis. J Limb Lengthen Reconstr [serial online] 2019 [cited 2019 Sep 15];5:22-6. Available from: http://www.jlimblengthrecon.org/text.asp?2019/5/1/22/265357


  Introduction Top


The incidence of posttraumatic distal radius growth arrest is relatively low, ranging between 1% and 7% of all physeal injuries.[1] As 85% of radius growth occurs at the distal physis, growth arrest of the distal radius usually causes significant shortening and deformity.[1],[2] In neglected cases, significant discrepancy occurs between the affected radius and the normal ulna and leads to radial deviation of the wrist joint, which usually results in considerable affection of both the shape and the function, including: pronation, supination movements, wrist dorsiflexion and palmar flexion, grip strength, in addition to the pain. The combination of multiple deformity components (shortening, angulation, and joint line deviation) renders it a surgically challenging problem. Ideal surgery should be directed to correct the radiological anatomy by restoring the normal length and joint orientation.

Little has been written about this problem, and only few cases of posttraumatic growth arrest have been reported in literature; however, several surgical techniques have been described to manage such cases, including ulnar epiphysiodesis, ulnar shortening osteotomy, bone grafting of the distal radius, and distraction osteogenesis of the distal radius using monolateral frame.[3],[4],[5],[6],[7] In general, these methods are more invasive and usually, do not address all deformity components present. In this study, we presented the management of posttraumatic distal radius by Ilizarov distraction osteogenesis, detailing some technical points of the procedure, to avoid such drawbacks and produce more consistently reproducible results.


  Patients and Methods Top


In this retrospective case series study, seven cases were operated in our department between the years 2015 and 2017. All cases had posttraumatic distal radius growth arrest that resulted in shortening with or without angular deformity. The management consisted of distal radius metaphyseal osteotomy followed by distraction osteogenesis using Ilizarov frame. The primary objective is to assess the functional and radiological outcome of this technique; secondary outcome measures include risk of complications, external fixator treatment time, total treatment time, and bone healing index.

All patients underwent history taking, examination including general and detailed local for the affected limb. Plain X-rays (anteroposterior and lateral views of both wrists and elbows), and computed tomography with three-dimensional reconstruction for the affected wrist region were performed for all cases to accurately measure bone length discrepancy, joint line orientation, and any associated angular deformity.

The age of patients ranged between 12 and 15 years (mean 13.1). There were four males and three females.

The inclusion criteria included all children with distal radius shortening secondary to posttraumatic growth arrest, with or without deformity. Patients with congenital causes of distal radius shortening (Madelung deformity) and mentally disabled children (poor compliance) were excluded from the study.

The youngest patient at the time of trauma was 10 years old and the oldest was 13 years old. The time interval between the original trauma and start of our management ranged from 12 to 24 months (mean 19 months).

The shortening present ranged from 1.8 to 3 cm (average 2.2 cm). The associated sagittal plane deformity was present in three cases in the form of volar tilt and ranged from 10° to 25° (average 16.6°) [Table 1].
Table 1: Patients preoperative data

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The left side was affected in four cases and right side was affected in three cases. The dominant side was the affected in three patients.

The procedure

The surgery in all patients was performed under general anesthesia, in the supine position, without tourniquet.

One 4 mm half pin was inserted from lateral to medial aspect, parallel to joint line, and distal to the planned osteotomy site. Another 4 mm half pin was inserted proximally at right angle to the anatomical axis of the shaft of the radius from dorsal to volar. Then, the frame is mounted on the pins.

2 half pins are attached proximally to the radius. Ulnar half pin was fixed to the proximal ring to maintain proximal radioulnar joint integrity (PRUJ) [Figure 1]. All pins were inserted through small stab wounds with a sleeve to avoid injury of the superficial veins and nerves.
Figure 1: Anteroposterior X-ray view showing the Ilizarov frame structure and osteotomy site

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An Ilizarov wire was inserted through the bases of the ulnar four metacarpal bones and fixed to the distal ring, in cases with significant shortening (more than 2 cm), to keep the wrist distracted and avoid its impaction during the lengthening process of the distal radius [Figure 2]a and b].
Figure 2: (a) Clinical photo showing the Ilizarov frame structure including the optional distal hand wire, (b) X-ray film demonstrating the frame structure and the distal hand wire position

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In cases of associated deformity, a hinge was applied to the distal ring and was inclined to match the joint orientation line.

A percutaneous osteotomy using multiple drills and osteotome was done in the distal radius metaphysis 1–2 cm proximal to the distal fixation pins [Figure 1].

Postoperative protocol

All patients were discharged, for outpatient clinic follow-up, on the second postoperative day, with detailed instructions about limb elevation during the first few days, pin site care, passive and active exercises for the wrist and fingers, and distraction mechanism.

Lengthening process began after 5–7 days in all cases, at a rate of 1 mm per day, divided as one-fourth every 6 h. The pronosupination was temporarily blocked during distraction, and when the X-rays showed adequate consolidation of the regenerate, the ulnar pin was removed to allow recovery of the forearm rotation while the frame is on awaiting full consolidation of the regenerate.

Radial lengthening was continued until complete deformity correction and restoration of radial length and ulnar variance. In three patients, with significant growth remaining, the radius was intentionally over lengthened to obviate the need for further lengthening procedure in case the distal ulna continued to grow.

Follow-up visits were every 2 weeks during the distraction phase then on monthly basis during consolidation phase. In all patients, the external fixator was removed after solid union (when at least three cortices out of 4 showed bony continuity). A short arm cast was applied for 1 month following the removal of the fixator followed by physiotherapy.

All patients were assessed radiologically by measuring radial shortening and ulnar variance, functional assessment was done using Mayo Wrist Score The Mayo Wrist Score requires both patient and physician participation to assess pain, the active flexion/extension arc (in comparison with the contralateral side), grip strength (in comparison with the contralateral side), the ability to return to regular activities, and the range of motion (ROM) in the affected hand only. Scores range from 0 to 100 with a score of 0 indicating a worse wrist condition and 100 indicating the best wrist condition.[8]


  Results Top


Follow-up ranged from 8 to 12 months (mean 10.3 months). Radiological correction was done in all cases with no radial shortening or positive ulnar variance. Mayo Wrist Score mean was 85.7 (range: 75 to 95) points. According to the Mayo Wrist Score, results were excellent in three patients, good in three patients, and satisfactory in one patient [Cases presentation: [Figure 3] and [Figure 4].
Figure 3: (a) Case one: Plain X-ray film showing the initial trauma of the patient, (b) X-ray film of the wrist and forearm demonstrating distal radius shortening and deformity, (c) Ilizarov frame mounted with the metaphyseal osteotomy done before distraction, (d) clinical photos of the patient's hand and wrist during distraction, ulnar half been was removed in this stage, (e) distraction osteogenesis at the osteotomy site with good bone regenerate, (f) clinical photos of the patient wrist after deformity correction, (g) final follow up X-ray film of the wrist

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Figure 4: (a) Case two: Radiological photos of the patient wrist and forearm demonstrating the severity of the deformity and radial shortening, (b) clinical photo of the deformity, (c) anteroposterior and lateral X-ray views showing the mounted Ilizarov frame and the distal osteotomy site, (d) clinical photos of the patient wrist showing correction of the deformity, (e) final follow-up X-ray film of the patient wrist

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The pronosupination ROM was measured preoperatively and at the end of rehabilitation, and all patients had no loss of the ROM compared to the preoperative one.

The mean external fixation time was 2.4 months (range from 2 to 3 months). The mean total treatment time was 3.5 months (ranged from 3 to 4 months). The mean bone healing index was 1.13 [Table 2].
Table 2: Patients postoperative data

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Superficial pin tract infection occurred in all cases and treated by pin site care and antibiotics; there was no deep infection. No incidence of neurovascular and superficial radial nerve injury. In one case, the frame was augmented by one wire distally from dorsolateral to volar medial, compression of the extensor tendons with correction lead to limited extension of the middle and ring finger; this was improved after wire removal with no residual consequences.


  Discussion Top


Physeal injuries constitute about 30% of long bone fractures in children,[9] twice as common in the upper limbs, with nearly two-thirds of forearm fractures occur in the distal radius. Yet, posttraumatic distal radius growth arrest cases are relatively few.[2]

Such cases usually present mainly with cosmetic and/or functional problems. Patients with distal radial shortening of more than one centimeter are usually symptomatic,[10] thus seeking correction. The optimum management of these type of deformities is still controversial.

Limited number of studies exists regarding the method of treatment, as this is a relatively uncommon problem. Moreover, reports in the literature describe the management of distal radius deformities, include mixed cases series, such as congenital cases, posttraumatic defects, especially in adults, and tumors.[11]

A number of surgical techniques for such cases have been described, including treatment with ulnar epiphysiodesis[3],[4] ulnar shortening osteotomy,[5],[6] lengthening osteotomy of the distal radius,[7] epiphysiodesis of the distal radius and ulna with an opening wedge osteotomy and bone grafting of the distal radius,[12] or even the Ilizarov technique.[13]

When compared with other methods, our technique proves some obvious advantages including precision of deformity correction and radial lengthening to the desired length without any grafting procedure. The circular frame has several advantages over monolateral fixator in that it allows multiplanar pin insertion for better stability of fixation, simultaneous lengthening and deformity correction and protection of the wrist and PRUJ during lengthening.

Similar results were achieved by Gündeş et al.,[14] who used using Ilizarov circular external fixator to treat radial shortening and severe wrist deformity due to neglected posttraumatic distal radius physeal arrest, their study included four patients, the mean Mayo Wrist Score was 89. Hosny and Kandel.[15] also showed comparable outcome, using distraction lengthening in five cases with posttraumatic radial club hand, with insignificant complications, and improved hand function (grip and power).

In our frames, using half pins distally allowed stiffer constructs, as two half-pins were put perpendicular to each other distal to the osteotomy, which could be performed very distal close to the center of rotation of angulation, thus permitting correction of relatively large degrees of deformity with lower complications rate with no need for readjustments of the frame.

The radius was intentionally over-lengthened in three patients for several reasons. First, the Distal radio-ulnar joint (DRUJ) is expected to be malformed due to lack of articulation between the distal radius and ulnar head, over-lengthening would serve as functional resection of the ulnar head. Second, those patients were relatively younger, significant remaining growth was expected, and the X-rays showed nonfused distal ulnar physis, over-lengthening of the radius would obviate the need for further lengthening procedure in case the distal ulna continued to grow.

Only few drawbacks can be observed; pin tract infection, relatively longer duration for deformity correction and that the DRUJ is not directly addressed.

Weak points of the study include small number of cases, although comparable to other studies, in addition to the short follow-up time. Longer follow-up is needed for better functional correlation. Longer follow-up can show more discrepancy in the radial height, as we did not attempt to map or excise the physeal bar, subsequenly, the recurrence of the deformity can occur, as the original pathology was not dealt with in our research. Furthermore, a more accurate calculation of the LLD at maturity can be done using different methods as Multiplier method[16], this can be very helpful to guide the lengthening and the overlengthening process during the management. Moreover, sensible statistical analysis could not be done due to the small number of patients included.


  Conclusion Top


Distraction osteogenesis, by Ilizarov external fixator, addresses the sequelae of posttraumatic distal radius growth arrest by restoring the normal anatomy in a controlled biological manner, without further grafting procedures through a minimally invasive approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Page WT, Szabo RM. Distraction osteogenesis for correction of distal radius deformity after physeal arrest. J Hand Surg Am 2009;34:617-26.  Back to cited text no. 1
    
2.
Canale ST. Fractures and dislocations in children. In: Canale ST, Beaty JH, editors. Campbell's Operative Orthopaedics. 11th ed., Vol. 2. Philadelphia: Mosby Inc.; 2008. p. 1533-6.  Back to cited text no. 2
    
3.
Bronfen C, Rigault P, Glorion C, Touzet P, Padovani JP, Finidori G, et al. Desepiphysiodesis – Elimination of partial premature epiphyseal closure. Experience of 17 cases. Eur J Pediatr Surg 1994;4:30-6.  Back to cited text no. 3
    
4.
Waters PM, Bae DS, Montgomery KD. Surgical management of posttraumatic distal radial growth arrest in adolescents. J Pediatr Orthop 2002;22:717-24.  Back to cited text no. 4
    
5.
Aminian A, Schoenecker PL. Premature closure of the distal radial physis after fracture of the distal radial metaphysis. J Pediatr Orthop 1995;15:495-8.  Back to cited text no. 5
    
6.
Valverde JA, Albiñana J, Certucha JA. Early posttraumatic physeal arrest in distal radius after a compression injury. J Pediatr Orthop B 1996;5:57-60.  Back to cited text no. 6
    
7.
Hove LM, Engesaeter LB. Corrective osteotomies after injuries of the distal radial physis in children. J Hand Surg Br 1997;22:699-704.  Back to cited text no. 7
    
8.
Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP 3rd, Linscheid RL. Scaphoid malunion. J Hand Surg Am 1989;14:679-87.  Back to cited text no. 8
    
9.
Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop 1990;10:713-6.  Back to cited text no. 9
    
10.
Cannata G, De Maio F, Mancini F, Ippolito E. Physeal fractures of the distal radius and ulna: Long-term prognosis. J Orthop Trauma 2003;17:172-9.  Back to cited text no. 10
    
11.
Bagatur AE, Doǧan A, Zorer G. Correction of deformities and length discrepancies of the forearm in children by distraction osteogenesis. Acta Orthop Traumatol Turc 2002;36:111-6.  Back to cited text no. 11
    
12.
Tang CW, Kay RM, Skaggs DL. Growth arrest of the distal radius following a metaphyseal fracture: Case report and review of the literature. J Pediatr Orthop B 2002;11:89-92.  Back to cited text no. 12
    
13.
Aston JW Jr., Henley MB. Physeal growth arrest of the distal radius treated by the Ilizarov technique. Report of a case. Orthop Rev 1989;18:813-6.  Back to cited text no. 13
    
14.
Gündeş H, Buluç L, Sahin M, Alici T. Deformity correction by Ilizarov distraction osteogenesis after distal radius physeal arrest. Acta Orthop Traumatol Turc 2011;45:406-11.  Back to cited text no. 14
    
15.
Hosny GA, Kandel WA. Treatment of posttraumatic radial club hand with distraction lengthening. Ann Plast Surg 2013;71:489-92.  Back to cited text no. 15
    
16.
16. Dror Paley, Anil Bhave, John E. Herzenberg and J. Richard Bowen. J Bone Joint Surg Am. 2000;82:1432.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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