FIGURE 3 - uploaded by Anil K Bhat
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A The arrow shows the uncorrected radial club hand. B The shaded area (straight arrow) shows the overlap of the carpus over the epiphysis on attempted passive correction (curved arrow). C The shaded area (arrow) shows the metaphyseal cuff osteotomy that will accommodate the overlap. D K-wire passed retrograde in order to achieve the alignment with the index finger metacarpal. E The ECU (a) is advanced distally and radial side tendons (b, c) are transferred to the ulnar side tendons.
Source publication
Various procedures described for deformity correction in radial longitudinal deficiency (RLD) have encountered problems of stiffness, instability, and inadequate correction. Many surgical modifications of these procedures have still resulted in deformity recurrence, shortening, and damage to the epiphysis. To align the hand with the forearm, the de...
Contexts in source publication
Context 1
... it is excised because it will prevent the distal and ulnar movement of the hand. 7 The distal end of the ulna is released, carefully preserving the cartilage and all vascularity of the epiphysis. The correctability of the carpus over the distal ulna is ascertained. The amount of longitudinal overlap of the carpus over the distal ulna is noted (Fig. 3A, B). The same amount of shortening is done at the metaphysis of the ulna subperiosteally about 2 cm proximal to the epiphysis. With the help of a microsaw, a cuff of bone is resected that is an average of 1 cm in width as calculated from the amount of overlap of the carpus over the distal ulna (Fig. 3C). ...
Context 2
... of the carpus over the distal ulna is noted (Fig. 3A, B). The same amount of shortening is done at the metaphysis of the ulna subperiosteally about 2 cm proximal to the epiphysis. With the help of a microsaw, a cuff of bone is resected that is an average of 1 cm in width as calculated from the amount of overlap of the carpus over the distal ulna (Fig. 3C). ...
Context 3
... the physis of the distal ulna, a 1.5-mm Kirschner wire (K-wire) is passed in a retrograde fashion into the ulna across the osteotomy site and then back into the second metacarpal (Fig. 4). The periosteum over the osteotomy site is closed. The insertion of the ECU is then advanced onto a more distal insertion to hold the wrist in ulnar deviation (Fig. 3D, E). Any additional extensors if present are transposed to the ulnar side. The capsule is sutured with overlapping toward the ulnar side. The extensor retinaculum is also tightened toward the ulnar side. The child is placed in an above-elbow cast with the wrist in slight ulnar deviation and extension. The 1-cm shortening will take ...
Citations
... Radialization combined with other procedures such as ulnar cuff osteotomy is also described for various radial longitudinal deficiency disorders. [11] Single-stage radialization technique also has been described to reduce the number of surgeries. [12] Radialization is well-described procedure, and many textbooks have separate chapters on radial club hand describing various techniques of its treatment. ...
Various terms in orthopedics are formed using or incorporating the name of native bones and these terms then describe a clinical entity or a procedure. The term thus created, however, may or may not be directly related to the bone associated. There are a few interesting examples of such terms that are encountered in the orthopedic literature. A short recollection of those few notable terms that have the name of a known bone within their terminology is described here for general reading and knowledge.
Keywords: Acetabulization, bones, olecranization, radialization, skeletal system, tibialization, ulnarization
... Recently, Bhat et al. 18 have introduced a different paradigm. They performed an ulna shortening in the diaphysis to achieve a stable reduction on the assumption that since no growth center is targeted, they believe the growth will continue, unaffected by the surgical shortening. ...
Purpose:
To study the long-term results of radial club hand, regarding ulna growth, radial angulation, and volar subluxation using a 2-stage treatment protocol.
Methods:
From 1998 to 2009, 39 radial club hands (32 patients) were treated with distraction, radialization, and a bilobed flap. Long-term follow-up was available in 13 patients (17 hands; average 12.6 years, range 9-16 years). All 17 hands were classified as Bayne and Klug grade 3 or 4.
Results:
The average age at distraction was 12 months (SD 5.3). The average age at radialization was 14 months (SD 5.8). At final follow-up, the average ulna length on the involved side was 69.3% of the uninvolved contralateral side in the unilateral cases. In the 4 bilateral cases, the average ulna length was 62% of the ulna length of a cohort of normal children. The transverse diameter of the ulna in the posteroanterior view was 79%, and in the lateral view 99%, of the radius on the contralateral side in the unilateral cases. The average radial deviation improved from 82° to 8° and the average volar subluxation improved from 20° to 12°. However, in 4 hands recurrent volar subluxation and required revision surgery.
Conclusions:
This approach to treatment was associated with consistent results in the correction of the radial angulation, volar subluxation, and ulna growth in long-term follow-up. Volar subluxation may result in a requirement for revision.
Type of study/level of evidence:
Therapeutic IV.
... Bhat et al. [31] reported on radialization with a form of shortening called a metaphyseal cuff osteotomy with additional tendon balancing. They claimed that the distal shortening allowed them to correct the RCH deformity without damaging the epiphysis or the carpus This article supports Paley relative length concept of ulnar shortening for acute correction of RCH [17]. ...
(1) Background: Patients treated with the two previous generations of ulnarization developed a bump related to the ulnar head becoming prominent on the radial side of the hand. To finally remedy this problem, a third generation of ulnarization was developed to keep the ulnar head contained. While still ulnar to the wrist center, the center of the wrist remains ulnar to the ulnar head, with the ulnar head articulating directly with the trapezoid and when present the trapezium. (2) Methods: Between 2019 and 2021, 22 radial club hands in 17 patients were surgically corrected with this modified version of ulnarization. (3) Results: In all 17 patients, the mean HFA (hand–forearm-angle) correction was 68.5° (range 12.2°–88.7°). The mean ulna growth was 1.3 cm per year (range 0.2–2 cm). There were no recurrent radial deviation deformities more than 15° of the HFA. (4) Conclusions: This new version of ulnarization may solve the problem of the ulna growing past the carpus creating a prominent ulnar bump. The results presented are preliminary but promising. Longer-term follow-up is needed to fully evaluate this procedure.
... 24 Bhat et al. have suggested that there is a mismatch of hypoplastic soft tissue structures and skeletal length in the forearm. 42 Deviation to the radial side increases due to tight soft tissues resulting in bowing of the ulna. The persistence of the hypoplastic structure on the radial side act as a deforming lever which may not be sufficiently countered by the tendon transfers.42 ...
... Shaving of the ulnar head or carpal bones to decrease the stress of the deforming lever may lead to ulnocarpal fusion and stiffness. 42 They have suggested a new technique of metaphyseal ulnar cuff osteotomy during radialization (Fig. 10). 42 After soft tissue release, the overlap between carpus and ulnar head is shortened at the metaphysis in the form of a subperiosteal cuff along with additional tendon balancing (Fig. 10). ...
... 42 They have suggested a new technique of metaphyseal ulnar cuff osteotomy during radialization (Fig. 10). 42 After soft tissue release, the overlap between carpus and ulnar head is shortened at the metaphysis in the form of a subperiosteal cuff along with additional tendon balancing (Fig. 10). This results in shortening of the ulna, but it helps in reducing the residual tightness on the radial side decreasing the deforming force of the lever. ...
s
Radial longitudinal deficiency represents a spectrum of musculoskeletal hypoplasia and dysplasia affecting the upper limb involving mainly the radial aspect of the forearm, wrist, and hand and not infrequently the proximal arm. 2/3rd of the patients with this condition suffer from an associated medical or musculoskeletal disorder and 1/3rd of them show features of a well-known syndrome with systemic manifestations. Hence it is mandatory to do a detailed clinical, radiological and laboratory evaluation which should also include genetic counselling and assessment. Its management has evolved greatly since the beginning of last century. The vast variations developed for the treatment only reflects on the persisting controversy on the ideal treatment which still eludes the medical fraternity. Current treatment options for wrist deformities include radialization or centralization with or without distraction which unfortunately has often shown poor outcomes with high rates of recurrence and poor growth of ulna leading some workers to suggest alternative techniques, which include microsurgical reconstruction using the proximal fibula and the second toe. The management of the associated hypoplastic thumb has been encouraging with recent improvements in classifications and increased options for milder deformities. The article reviews the management options available for this common condition with respect to the recent developments in literature
... La gravedad de estas características anormales adicionales es paralela a la que alcanza la deficiencia radial. 2 En la mayoría de los casos, la alineación de la mano es casi perpendicular al antebrazo, lo que produce un acortamiento general, una apariencia antiestética y una función de la mano reducida. 5 Clasificación La clasificación de la condición fue presentada inicialmente por Bayne y Klug 2 como tipos I a IV en 1987, en función del aspecto radiográfico del radio. Esta clasificación fue ampliada por James et al. 6 en 1999 para reconocer las deficiencias de los lados radiales limitadas al carpo (tipo 0) y al pulgar (tipo N). ...
... La introducción de la distracción de tejidos blandos por Kessler en 1989 simplificó aún más estos problemas, lo que facilitó el reposicionamiento del carpo y la solución del déficit de la piel en el momento de la cirugía. 5 Se han descrito la centralización, la radialización y las modificaciones sugeridas para corregir esta deformidad y restablecer la alineación de la mano con el antebrazo. Sin embargo, estas modificaciones frecuentemente resultan en una función de la mano comprometida con recurrencia de la deformidad. ...
... Sin embargo, estas modificaciones frecuentemente resultan en una función de la mano comprometida con recurrencia de la deformidad. 5 La centralización del cúbito ha resultado en una muñeca menos funcional debido a la fusión del cúbito distal con el carpo y en una longitud reducida del antebrazo derivada del daño de la epífisis cubital distal. La recurrencia de la deformidad sigue siendo alta. ...
Introducción:
La mano zamba radial congénita se caracteriza por la desviación radial de la mano como resultado de hipoplasia o ausencia del radio.
Material y métodos:
Se realizó un estudio descriptivo, retrospectivo, transversal y observacional de los pacientes activos con diagnóstico de mano zamba radial.
Resultados:
Se estudiaron 71 pacientes y 92 extremidades, la prevalencia en nuestro hospital fue de 0.08%, 64.7% fueron hombres y 35.3% mujeres. Se observaron 22 pacientes con afectación de la extremidad torácica derecha, 28 de la izquierda y 21 pacientes bilateral. Se encontró que 93% de los pacientes presentaban un síndrome asociado. El tipo de displasia longitudinal radial más común fue la tipo I. Cincuenta y ocho extremidades no contaban con pulgar. El Estado de México es el más afectado y 91.6% contaban con un responsable tutelar con escolaridad máxima de preparatoria.
... La gravedad de estas características anormales adicionales es paralela a la que alcanza la deficiencia radial. 2 En la mayoría de los casos, la alineación de la mano es casi perpendicular al antebrazo, lo que produce un acortamiento general, una apariencia antiestética y una función de la mano reducida. 5 Clasificación La clasificación de la condición fue presentada inicialmente por Bayne y Klug 2 como tipos I a IV en 1987, en función del aspecto radiográfico del radio. Esta clasificación fue ampliada por James et al. 6 en 1999 para reconocer las deficiencias de los lados radiales limitadas al carpo (tipo 0) y al pulgar (tipo N). ...
... La introducción de la distracción de tejidos blandos por Kessler en 1989 simplificó aún más estos problemas, lo que facilitó el reposicionamiento del carpo y la solución del déficit de la piel en el momento de la cirugía. 5 Se han descrito la centralización, la radialización y las modificaciones sugeridas para corregir esta deformidad y restablecer la alineación de la mano con el antebrazo. Sin embargo, estas modificaciones frecuentemente resultan en una función de la mano comprometida con recurrencia de la deformidad. ...
... Sin embargo, estas modificaciones frecuentemente resultan en una función de la mano comprometida con recurrencia de la deformidad. 5 La centralización del cúbito ha resultado en una muñeca menos funcional debido a la fusión del cúbito distal con el carpo y en una longitud reducida del antebrazo derivada del daño de la epífisis cubital distal. La recurrencia de la deformidad sigue siendo alta. ...
Introduction:
Radial club hand is characterized by radial deviation of the hand, as a result of hypoplasia or absence of the radius.
Material and methods:
A descriptive, retrospective, cross-sectional and observational study of active patients diagnosed with radial club hand at the Shriners-Mexico Hospital was carried out.
Results:
We studied 71 patients and 92 limbs, the prevalence was 0.08%, 64.7% were men and 35.3% women. We observed 22 patients with involvement of the right thoracic extremity, 28 left and 21 bilateral. It was found that 93% of the patients had an associated syndrome. The most common type of radial longitudinal dysplasia was type 1. 58 limbs did not have a thumb. The State of Mexico is the most affected and 91.6% had a guardian with maximum high school education.
The Oberg-Manske-Tonkin (OMT) classification of congenital hand and upper-limb anomalies continues to be refined as our understanding of the genetic and embryonic etiology of limb anomalies improves.
➤ We have conducted an evaluation of graft and graftless techniques for syndactyly reconstruction; strengths and drawbacks exist for each technique.
➤ Treatment for radial longitudinal deficiency remains controversial; however, radialization has shown promise in early follow-up for severe deformities.
➤ Recent emphasis on psychosocial aspects of care has demonstrated that children with congenital upper-limb differences demonstrate good peer relationships and marked adaptability.
Addressing the deforming stresses arising from soft tissue and continued skeletal development is crucial to obtain long-term correction of forearm carpal alignment in Radial longitudinal deficiency. The aim of the present study was to report the medium-term follow-up results of radialization with ulnar cuff osteotomy in children. A total of 17 patients (21 involved limbs) with a mean follow-up of 66 months (range 50 to 96) were reviewed. Mean correction of the hand forearm angle at the final follow-up was 51°. Mean hand forearm position preoperatively and at the final follow-up were −1.1 cm (SD 0.9) and +1.3 cm (SD 0.8), respectively. This metaphyseal osteotomy relaxed the radial structures throughout the original phase of deformity correction. The mean ulnar growth was 62% of the contralateral side at the final follow-up. Our technique may provide a feasible solution to the correction and prevent recurrence of deformity while maintaining ulnar growth in the medium to longer term.
Level of evidence: III
Introduction
Radial longitudinal deficiency (RLD) includes bone, musculotendinous and neurovascular abnormalities of multifactorial aetiology of the radial side of the upper extremity. Treatment includes improving the length of the limb, the appearance and functioning of the hand. The aim of this study was to present our experience in a series of patients attended over the past 15 years and to describe the clinical and radiological results.
Methodology
A retrospective study of patients with RLD between 2000 and 2016. Variables were analysed and age associations were identified at the time of surgery, sex, laterality, type of deformity according to the modified Bayne–Klug classification, surgical technique, physis damage, associated diseases, functional and radiological results.
Results
47 cases of 65 met the inclusion criteria. The average age of surgery was 19 months, 61% female. According to classification 60% were type IV, type III in 19%, type 0 in 17% and type I in 4%. The intervention was centralization 72.3%, radialization 8.5% and one case of lengthening. Ulna osteotomy was performed in 55.3%. There was damage to the physis in 31%. The postoperative radiological position was neutral in 48.9%.
Conclusions
In patients with centralization at 1 year, good clinical and radiological correction were observed, however this was lost over time. The management of soft tissues prior to centralization is believed to give better results. The use of intramedullary nail from the ulna to the carpus could be associated with damage to the distal ulna.
