A novel technique of ulna strut grafting for post-septic radial clubhand deformity: Case series of 4 patients with review of literature

Abstract

Background: Though distal end radius fractures are one of the commonest fractures to occur, their nonunions are extremely uncommon. Out of these, post-septic defect nonunions with acquired radial clubhand deformity are even more rare and pose unique problems in management. We present a case series of 4 patients of post-septic radius nonunion with acquired radial clubhand deformity successfully treated with a novel technique of using Ulna Strut grafting for radius defect after ulnar shortening. All 4 patients have a good functional and cosmetic outcomes with radiological union at the cost of minimal limb length discrepancy of the forearm.

Methods: This is a case series of 4 patients with a retrospective study design and study duration of 3 years from August 2016 till March 2019.4 patients presenting to us with post-septic defect nonunions of radius with an acquired radial clubhand deformity were selected with a mean age of 19.75 years which included 2 males and 2 females.

Results: The mean time for radiological union was 3.125 months. The average range of motion at the wrist joint was 35° of flexion and 50° of extension with average protonation being 47.5° and supination being 75°.There were no subsequent complications reported in these patients except for a minimal limb length discrepancy with satisfactory functional outcomes in all the patients.

Conclusion: The use of Ulnar shortening and Ulna strut grafting for the treatment of defect nonunions of radius with acquired clubhand deformity yielded predictable results. It is a simple procedure that does not require additional training, with no additional morbidity of iliac crest or fibula bone grafting and had a minimum complication rate. The technique looks promising in the future, though a study on a larger population would further strengthen the predictability of this unique technique.

Fig. 1

Treatment strategy in a 29 yr/M with distal radial shaft nonunion. 1a. X-ray of 29 year/M with defect nonunion of distal end radius and Distal radio-ulnar joint disruption. 1b. Clinical pics of radial clubhand deformity showing dorsal ulnar subluxation. 1c. First stage with insertion of antibiotic cement spacer in the defect and stabilisation with plating. 1d. Postop Xray after first stage. 1e. Second stage with removal of cement spacer. 1f. Harvesting ulna strut graft and ulnar shortening with correction of ulnar variance using standard approach. 1g. Postop Xray at 1 year followup showing complete radiological union and ulna graft incorporation. 1h. Clinical pics showing good functional and cosmetic outcomes at the end of 1 year.

Fig. 2

Treatment strategy in a 11 year old boy with distal end radius nonunion. 2a. X-ray showing gap nonunion with gross distal radio-ulnar joint disruption. 2b. Clinical pics with radial clubhand deformity with on and off discharging sinus. 2c. First stage showing the defect site with ivory white sequestrum. 2d. Removed sequestrum. 2e. Postop Xray after first stage of debridement and cement spacer and stabilisation with external fixator. 2f. Second stage intraoperative pic showing induced membrane formation. 2g. Harvesting ulna strut graft and ulnar shortening with correction of ulnar variance using standard approach. 2h. Postop Xray at 1 year followup showing complete radiological union and ulna graft incorporation. 2i. Clinical pic showing completely healed scar and good cosmetic outcome at the end of 1 year.

Fig. 3

Single Stage treatment strategy in a 17 year old female with distal end radius nonunion with no signs of infection and normal blood parameters. 3a. Xray showing defect nonunion of shaft radius with acquired radial clubhand deformity. 3b. Immediate postoperative X-ray showing correction of ulnar variance and use of ulna strut graft as a single stage procedure. 3c. Postoperative Xray at one year followup showing complete radiological union and restoration of normal wrist parameters. 3d. Clinical pics showing good functional outcomes at one year followup.

Fig. 4

Treatment strategy in a 12 year old female with distal end radius nonunion. 4a. Xray showing pathological fracture with features of chronic osteomyelitis. 4b. Intraoperative pic showing ivory white sequestrum with no evidence of bleeding on drilling. 4c. 5 cm long sequestrum. 4d. Insertion of cement spacer in the defect. 4e. Postoperative Xray after debridement and cement spacer and stabilisation of external fixator. 4f. Postoperative Xray one year after the second stage showing complete radiological union. 4g. Clinical pic showing functional outcomes at the end of one year.