Sunday, 20 May 2012

Case 2 - Forearm Deformity

Clinical Picture and movements at presentation

This 15 year old girl was a precious child for her parents, born after many attempts of IVF. 

She had a short and bowed forearm, and in addition had an unsightly prominence in the lateral aspect of the elbow. 

She also complained of pain when she had to do any writing tasks for a long time. 

Xray at presentation

Xrays revealed an exostosis at the distal ulna, which caused a short ulna, which in turn by the check rein effect caused an exaggerated bowing of the radius and dislocation of the head of the radius. Some surgical procedure had been attempted in the past, details of which were unavailable.

The challenge here was to correct the bowing deformity, as well as the prominence of the radial head, without much surgical scars.

We first excised the ulnar exostosis. 6 weeks after that, we applied a pediatric LRS fixator on the ulna.
The trick here was to put in the proximal and distal set of pins without the rail, such that each set of pins was perpendicular to that segment of bone.

C arm pictures of fixator application & osteotomy

Once the clamps were fixed to the rails, the bowing of the ulna was automatically corrected.

Due to the acute correction, instead of the normal 7 days, we began lengthening after 10 days, and continued lengthening, till the distal end of the ulna reached the carpus / distal end of radius.

Sequential Xrays of Ulnar Lengthening
Once the Ulna was at the desired length, she was taken to theatre, and the distal end of the ulna was locked or coupled to the distal end of the radius, by means of 1 screw and 1 K wire, put in percutaneously.

C arm pictures of insertion of Screw and K wire
The ulnar lengthening was then continued, till the radial head prominence disappeared. No attempt was made to reduce the radial head, because even preoperatively, with the gross dislocation of the radial head, she had a good range of movements. We anticipated that she would retain good movement, and IF required, an excision of the radial head could be done later.

The Radial Head moves distally
Function was encouraged while in the fixator, and when the regenerate appeared healed well, the fixator was removed.

Function with the Fixator
Healed regenerate
She had good function equal to her preoperative status even at 1 week post removal
Scars and Prono-Supination
The bone was healed well as confirmed on various views.

At her one year followup, she is obviously a happy patient, free of her deformity, and her complaints.
Notice the the bump of the radial head is hardly (if at all) visible.

She is now back at her village, attending Junior College.

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