Transcript radial hand - Dror Paley, MD"Lengthening.us"

Radial Club Hand
Correction of Deformity
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Centralization
Radialization
Distraction
Distal Ulnar Osteotomy
Problems:
1. High recurrence rate
2. Growth arrest distal ulna
New Method:
Ulnarization (Paley 1998)
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Modification of Buck Gramko method
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Buck Gramko: called this radialization since
makes ulna into a radius
Paley: called this ulnarization since moves carpus
to the ulnar side of the ulnar head
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Ulnarization of the Carpus
with
Tendon Transfer of FCU
RCH: Poor Grip Strength
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Due to lack of fulcrum
Forearm shortening affects muscle length curve
(Blick’s)
Excessive palmar flexion pull: dorsi flexion of
hand increases grip strength
Ulnarization
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Converts head of ulna into a fulcrum due to
radial pull of muscles
fulcrum
Muscle pull
Flexor Carpi Ulnaris Transfer
•FCU is the major deforming flexor force
•Transfer to dorsum converts it to a correction force
•This helps improve finger flexion ROM and strength
Lengthening
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Improves muscle tension (Blick’s curve)
Improves grip strength
Ulnarization vs Radialization
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Paley (1998)
Name describes direction of
carpal translocation
Volar approach
Visualize all the N-V
structures
Transfer FCU tendon
Extensile for elbow
contracture release
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Buck-Gramko (1979)
Name describes change of
ulna to a radius
Dorsal approach
Cannot visualize N-V
structures
Transfer FCR*
*FCR usually absent
8 year followup
7 yr. followup radiographs
Ulnarization: Results
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15 patients; 21 hands
Followup 1-7 years
Recurrence: 0
Growth arrest: 0
Ulnarization: Complications
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2 skin necrosis treated by debridement and
secondary closure
Wrist Dorsiflexion
PASSIVE
preop -15°
postop +36°
ACTIVE
postop 9°(10-20°)
Preop: 79mm (40175mm)
Postop: 102mm
(58-188mm)
No Growth Inhibition
Conclusion
• safe
• no recurrences
• no growth arrest
• low complication rate
• improves grip strength
• active dorsiflexion
• improves activities of daily living
• improves cosmesis
Lengthening of the
Forearm for
Radial Clubhand
Strategy
Dependent on age at presentation
Age 610 years
Two lengthenings
• Before age 10 years
st
1 lengthening 4-6 cm
• After age 10 years
nd
2 lengthening 6-8 cm
before
after
normal
Before vs After 1st Lengthening vs Normal side
preop
1st lengthening:
7cm
1st lengthening
8cm
2nd
lengthening
2nd
lengthening:
10cm
10cm
Total length gain 18 cm
7 y.o. girl with rch and partial growth arrest
1st Lengthening: 6cm
before
after
2nd Lengthening
Strategy
Dependent on age at presentation
• Age 1120+ years
one lengthening 812 cm
Distal Ulnar Osteotomy
Reorient Original Ulno Carpal
Psuedo Joint
16y Radial clubhand
1y centralization
2y pollicization
12 Feb03
Osteotomy R ulna + application TSF
Intraop
Post-op
During distraction
4 months post op.
Materials
• 24 forearms
• 20 patients
Range of Motion
Decreased
Same
Increased
0
1
4
Complications
Refractures
3
Premature
Consolidation
1
Reoperation for
Complications
2
Grip Strength
Improved
Worsened
24/24
0/24
Follow-up
Mean
Range
10 years
113 years
Lengthening
Age (yr) Range (cm) Mean (cm)
69
1014
58
810
7
9
Lengthening
Once
24
Twice
Total
6
28
Range of Motion
• Finger flexion: increased range and grip strength
in all patients
• Finger extension: decreased MCP extension
in 2 patients (20°)
• Elbow extension: transient contracture in all
patients, return to preop levels in all
• Elbow flexion: improved in 2 and unaffected in 7
Lengthening Amount
• Mean, 7.6 cm
• Range, 511cm
Strategy
This study
Age 05 years: correction hand/pollicization
6
Age 610 years: 1st stage lengthening
12
Age 11-16 years: 2nd stage lengthening
6
Age 1120 years: one lengthening
6
Additional Deformity Correction
• Distal ulnar osteotomy for hand and
angular realignment
• Mid ulnar osteotomy for correction of
ulnar bow
• Bilaterals:
Supination of forearm at end of
lengthening for perineal care
Conclusion
• safe
• low complication rate
• improves grip strength
• improves pollicization pinch
• improves ADL
• improves cosmesis
• improves body image