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191.The Wrist: Diagnosis and Operative Treatment 77

For late presentation of distal radius fracture malu- nion.an osteotomy through the distal radius to realign the artic¬ular joint surface and correct any excessive dorsal angulation is necessary to correct the instability.11-" The surgical technique roust be modified to ibe number of planes of correction required.Dorsal angvdalion akmc, without his of radius height or ulnar inclination, requires d.irul open-wedge osteotomy with a wedge- shaped interposition iliac crest bone graft (see Chapter 15). The osteotomy is best performed at a href="http://www.discountshapeup.com/">Skechers Shape UPS tbe site of malunion to prevent an bend-in the dislal radius and to minimise the amount of angu lar cotrvction required Cats- must Isj taken to place tbe frift prox¬imal to the distal radioulnar joint. Either a btvorlscal dor».il-ba«d. intercalary graft or two wedge-shaped trkorticocancclloux grafts are cut from the Qiac crest. The surgical technique b to cu. Ihe graft through the inner and outer tables with a power saw to give the exact angular correction required. Triangular cortical Shape UPS wedges (inner and outer tables) and ibe dorsal cortical crest maintain

con¬tact between corticjl bone surfaces for correction of deformity and allow maximum cancellous banc suifsce area contact for osteosyn- Ihcsis (Fig. 2ts7).Techniques described by Fernandez are helpful. These involve careful preoperative measurement of the angulation of tlw distal Sketchers Shape UPS radius (dorsal and radial-ulnar) as well as live normal contralateral wrist. If the normal 22-degree ulnar inclination of'the radius articular surface has been last, then ihe nvorc radial of the two tri¬angular grafts is cut wilh greater angulation lo open lite radial side of the- osteotomy more than ihe ulnar side (Fig. 26.7). If. in addition to dorsal till and loss of Shape UP Skechers ulnar inclination, impaction hasshortened Ihe radius, then the triangular grafts .ire replaced by iivipe/.t AIHI grafts to displace the radial fragment distally to gisv neutral ulna variance IFig 26.$). Once the graft hoc been \ut. the defect (deficiency) in the distal radius can be corrected by a lam¬ina spreader or with an external fixation distraction system. Depending on the location of the osteotomy, the correction obtained wilh the opening-wedge graft can be maintained by cither a plate with screws (Figs. 2/.'M and 26-10) or a tension band wire iFig, 26.98). Dorsal osteotomies that Skechers are placed too far dis¬till;' may prevent the ute of plate and screw fixation owing to extensor tendon interference. Simple and effective fixation can be achiesed with dortal tension hand wiring that utet two parallel Kirschner wires (Fig. 26.9B).Author's Preferred Technique for Corrective OsteotomyIhe Kirschner wires are driven from the dittal radius distoll; and dorsally in a proximal and palmar direction through the bone graft to engage tbe palmar cortex of the radius (Fig, 26.9B). This, com¬bined with the dorsal tension band wire, prevents dorsal extrusion ol the bone graft. The distal w ire can go either around or through the distal portion of the radius at long at it avoidt the joint articu¬lar surface.

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