AOTrauma Masters CourseCurrent Concepts Module 4 Discussion 3

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AOTrauma Masters Course—Current Concepts Module 4, Discussion 3, Case 5: Nonunion distal radius Davos

AOTrauma Masters Course—Current Concepts Module 4, Discussion 3, Case 5: Nonunion distal radius Davos Courses December 2018

Case description • 35 -year-old man • 2005: - Open fracture - 1 month

Case description • 35 -year-old man • 2005: - Open fracture - 1 month in intensive care unit - Open reduction and internal fixation: volar plate • 2006‒ 2008: - Hardware removal - Iliac crest bone graft - Plating twice • 2009: - Late removal and Sauvé-Kapandji procedure - No infection

2008: Distal radius nonunion

2008: Distal radius nonunion

2010: Distal radius nonunion and S-Kapandji

2010: Distal radius nonunion and S-Kapandji

Discuss 1. 2. 3. 4. 5. Describe the complication Treatment options Approach Method of

Discuss 1. 2. 3. 4. 5. Describe the complication Treatment options Approach Method of fixation Rehabilitation

Treatment options 1. Total wrist fusion 2. Radiocarpal fusion, spearing the midcarpal joint 3.

Treatment options 1. Total wrist fusion 2. Radiocarpal fusion, spearing the midcarpal joint 3. Darrach procedure alone 4. New bone graft and bone fixation 5. No solution is feasible

Which kind of graft? 1. Iliac crest bone graft 2. Allograft or bone substitute

Which kind of graft? 1. Iliac crest bone graft 2. Allograft or bone substitute 3. Local graft 4. Vascularized bone graft 5. Bone morphogenetic protein

Bone debridement

Bone debridement

Bone alignment and fixation

Bone alignment and fixation

Which vascularized bone graft? • • • Local: Mathoulin, Zaidenberg or metacarpal Fibula Medial

Which vascularized bone graft? • • • Local: Mathoulin, Zaidenberg or metacarpal Fibula Medial femoral condyle Iliac crest From the foot Distal, lateral humerus

Medial femoral condyle graft

Medial femoral condyle graft

Periosteal bleeding after tourniquet release

Periosteal bleeding after tourniquet release

Long pedicle can be obtained Del Piñal F, García-Bernal FJ, Regalado J, et al.

Long pedicle can be obtained Del Piñal F, García-Bernal FJ, Regalado J, et al. Vascularised corticoperiosteal grafts from the medial femoral condyle for difficult non-unions of the upper limb. J Hand Surg Eur Vol. 2007 Apr; 32(2): 135‒ 142. Rodríguez-Vegas JM, Delgado-Serrano PJ. Corticoperiosteal flap in the treatment of nonunions and small bone gaps: technical details and expanding possibilities. J Plast Reconstr Aesthet Surg. 2011 Apr; 64(4): 515‒ 527.

Bone healing at 3 months

Bone healing at 3 months

Bone remodeling at 5 years

Bone remodeling at 5 years

Functional flexo-extension

Functional flexo-extension

Forearm rotation

Forearm rotation

Learning objectives • Describe injury • Outline principles of treatment of the nonunited distal

Learning objectives • Describe injury • Outline principles of treatment of the nonunited distal radial fracture • Explain benefits of vascularized bone graft in the recalcitrant distal radial nonunion • Discuss treatment options • Select appropriate treatment