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C
5%
38/812
D
82%
667/812
E
7%
58/812
F
2%
13/812
None, acute surgery is contraindicated for this patient.
19/812
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This otherwise healthy patient is presenting to your clinic with a significant nascent malunion of the distal radius. The best option for this patient is acute distal radius corrective osteotomy (Answer 2). Distal radius fractures are the most common fracture in adults. They typically occur secondary to a fall onto an outstretched hand, and 50% have intra-articular involvement. The distal radius is responsible for 80% of the axial load weathered by the wrist joint in the uninjured state. In patients under the age of 65, nonoperative management is typically indicated for extra-articular fractures with less than 5mm of radial shortening and less than 5 degrees of dorsal angulation, or angulation that is within 20 degrees of the contralateral side. Nonoperative management requires radiographic surveillance in order to monitor for the progression of malunion, which can have markedly deleterious effects on wrist function and biomechanics. The treatment of choice for nascent malunion in otherwise healthy and active young patients is immediate corrective osteotomy of the radius. Jupiter and Ring evaluated the outcomes of early (mean 8 weeks) corrective osteotomy for distal radius malunion. Ten patients underwent early osteotomy, and these outcomes were compared to ten patients who underwent delayed (mean 40 weeks) reconstruction. While outcomes were comparable between the two groups, early reconstruction was associated with a shorter period of overall disability, and in the opinion of the authors was a technically less-challenging procedure. Bilgin and Armangil reported on the outcomes of early corrective osteotomy in 11 patients with nascent malunion. Their study included 11 patients with a mean age of 36 years. All 11 patients were able to return to their previous level of function, and only one patient required structural bone grafting. The authors conclude that the advantages of an early corrective osteotomy include anatomic restoration at the original fracture line, a shortened healing period, and a decreased need for structural bone grafting. Figure A demonstrates an early distal radius malunion, with marked loss of radial height and substantial dorsal angulation. Figure B demonstrates a normal lateral radiograph of the wrist. Figure C demonstrates a wrist arthrodesis, Figure D demonstrates a distal radius corrective osteotomy, Figure E demonstrates an ulnar shortening osteotomy and Figure F demonstrates a Darrich procedure (ulnar head resection). Incorrect Answers Answer 1: A wrist fusion may be a salvage procedure in a low-demand patient with late-stage wrist osteoarthritis. It is not appropriate in this young patient with nascent malunion. Answers 3 and 4: An ulnar shortening osteotomy or Darrach may be indicated in the setting of ulnar abutment syndrome, or in concert with a distal radius corrective osteotomy; however, they will not correct the substantial angular malunion the patient currently has. Answer 5: Acute treatment is associated with a technically easier surgery and a lower need for structural bone grafting. Furthermore, the patient is presenting with marked shortening and apex-volar displacement, necessitating surgical intervention.
2.1
(8)
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