J Korean Fract Soc.  2017 Oct;30(4):209-218. 10.12671/jkfs.2017.30.4.209.

Malunion: Deformity Correction of the Upper Extremity

• Cha SM
• Shin HD

• KMID: 2424134
• DOI: http://doi.org/10.12671/jkfs.2017.30.4.209

Abstract

Malunions after fractures are classified as shortened, angulated, torsion, or rotational deformities that is outside the acceptable range, regardless of the location, whether upper or lower extremity. The distinct feature of a malunion in the upper extremity is that it is free from weight bearing; thus, some degree of shortening is allowed compared with the contralateral normal side in long bones, such as the humerus, radius, or ulna. However, malunions associated with functional impairment, especially angulated or rotational deformities, are more likely to develop instability, degenerative lesions, or rarely, compressive neuropathy. Hence, malunions with such association may occasionally require correction.

Keyword

Upper extremity; Malunion; Deformity

MeSH Terms

Congenital Abnormalities*
Humerus
Lower Extremity
Radius
Ulna
Upper Extremity*
Weight-Bearing

Figure

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  Fig. 1 Model of lIizarov apparatus for lengthening of the humerus.

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  Fig. 2 Schemati drawing of supracondylar quadrilateral displacement osteotomy. (A) ∠CAB: correction angle BC=CZ, DC=AZ, ΔAZC: DCB, □ZADC: being removed part. (B) After supracondylar quadrilateral displacement osteotomy, the distal fragment was medially displaced (AD distance) and wedge (AZC) was formed on line AC. (C) After French osteotomy (lateral closing wedge osteotomy), the prominence of lateral condyle becomes positive (author's method).

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  Fig. 3 Step-cut osteotomy. Cited from the article of Moradi et al. (Clin Orthop Relat Res, 471: 1564-1571, 2013) with original copyright holder's permission.13)

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  Fig. 4 The dome osteotomy. Point A marks the intersection of the midline axis of the humerus with the olecranon fossa. AB is drawn perpendicular to the midline axis of the humerus. AB' is drawn parallel to the (altered) distal humeral joint line, so that the angle BAB' marks the angle needed for correction. The dome is then drawn with line AB' as its radius. After the dome osteotomy is completed, the distal humerus is rotated so that B and B' are the same point. Cited from the article of Bauer et al. (J Hand Surg Am, 41: 447-452, 2016) with original copyright holder's permission.16)

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  Fig. 5 Three-dimensional osteotomy. Dotted lines represent the planned osteotomies, which are made using preformed patient-specific cutting guides. Cited from the article of Bauer et al. (J Hand Surg Am, 41: 447-452, 2016) with original copyright holder's permission.16)

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  Fig. 6 Oblique corrective osteotomy for a malunited diaphyseal fracture of the forearm. Comparison radiograph—antero-posterior (AP) and lateral views of the left forearm malunion and the normal contralateral side. Clinical demonstration of preoperative rotational profile. Operative technique with exposure of the malunion site, plate contouring, oblique osteotomy and stabilization of the osteotomy site. Postoperative radiographs—AP and lateral views as well as a postoperative range of motion. Cited from the article of Jayakumar and Jupiter (Hand (N Y), 9: 265-273, 2014) with original copyright holder's permission.25)

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  Fig. 7 Single-cut corrective osteotomy for a malunited diaphyseal fracture of the forearm. Preoperative clinical image and radiograph of a complex malunion of the forearm. Computed tomography-guided development of a plastic model of deformity to aid preoperative surgical planning and simulation of bone wedge excision in the true plane of deformity. Operative technique with exposure of the malunion site, single-cut osteotomy, temporary stabilisation with external fixator and definitive plate stabilisation of the osteotomy site. Postoperative radiographs—antero-posterior and lateral views. Cited from the article of Jayakumar and Jupiter (Hand (N Y), 9: 265-273, 2014) with original copyright holder's permission.25)

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  Fig. 8 Osteotomy must be parallel to the articular surface to avoid creating a secondary deformity.

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  Fig. 9 Preoperative planning for the opening wedge dorsal osteotomy and fixation with the minicondylar plate.

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  Fig. 10 Preoperative radiographs and planning: An opening wedge osteotomy was performed via a volar approach and fixed with a fixedangle plate and morcellized cancellous bone. Preapplication of the fixed-angle plate to the distal fragment at the anticipated angle of correction with two parallel pegs allowed the surgeon to subsequently remove the plate, make the osteotomy, and then reattach the plate to precisely rotate the distal fragment.

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