eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Ulnar Clubhand: Treatment

Author: Minoo Patel, MBBS, MD, MS, FRACS, Senior Lecturer, Monash University, Melbourne, Australia; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Melbourne, Australia
Coauthor(s): John Herzenberg, MD, FRCSC, Professor, Department of Orthopedic Surgery, Associate Professor, Department of Pediatrics, University of Maryland Medical School, Codirector of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore
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Updated: Oct 19, 2007

Treatment

Surgical Therapy

• Ulnar deviation – Casting from birth, long-arm cast, gradual stretching of the tight ulnar structures. (Mild cases will correct by age 6 mo.)
• Anlage
  • Early presentation – Excise the anlage before the occurrence of radial bowing or radial head dislocation, around age 6 months. The procedure is performed through an ulnar incision along the wrist. Care is taken to protect the ulnar artery and nerve. Excision of the entire anlage is not necessary; at least 50% should be excised. The wrist is placed in maximal radial deviation in a long-arm cast for a month. Night splints are worn for up to 6 months to maintain the correction.
  • Late presentation – Excise the entire anlage. Z-plasty of the skin and selective tenotomies may be necessary.
  • Radiohumeral synostosis – The anlage should be excised, as the anlage tether can cause progressive bowing.
• Bowing of the radius – Radial corrective osteotomy
• Forearm is in a less than useful rotation - Radial corrective osteotomy. (It is better to wait until the child is mature enough to make a decision about the appropriate position.)
• Radial head dislocation – Observe, resection only, or resection with the creation of a single-bone forearm. (Ulnar osteotomy has been performed with or without shortening, with open reduction and stabilization of the radial head and plus/minus early radial head prosthetic replacement.² A single-bone forearm is created through a posterior approach, protecting the posterior interosseous nerve. A sufficient amount of proximal radius is excised to achieve proper approximation and alignment with the ulna. An intramedullary nail or a plate is used for stabilizing the fusion.)
• Unstable elbow – Ulnohumeral or radiohumeral arthrodesis or elbow ligamentous reconstruction
• Radiohumeral synostosis
  • Young children: Excise the ulnar anlage.
  • Older children: Perform a distal humeral osteotomy to improve forearm alignment.

Distraction reconstruction treatment

Paley and Herzenberg combined the classifications of Kummel, Ogden, Swanson, and Johnson and Omer to create a classification that relates directly to the treatment strategies of ulnar deficiencies of the forearm as follows³ :

• Type 1 – Hypoplastic ulna with the distal epiphysis intact. This type is the most common with congenital dislocation of the radial head.
• Type 2 – Absence of the distal third of the ulna
• Type 3 – Absence of the distal two thirds of the ulna
• Type 4 – Complete absence of the ulna
• Type 5 – Radiohumeral synostosis

Treatment algorithms

Type 1 without radial head dislocation

This type is treated with ulnar lengthening, radius shortening, or both. Large amounts of radial shortening can result in radial head instability and dislocation. The radial bow is also corrected through the distraction osteotomy.³ The treatment is repeated throughout childhood as the limb grows and as the discrepancy increases.

Type 1 with radial head dislocation

The radial head dislocation probably represents a relatively longer radius in the presence of a short ulna. The radial head can be left in its dislocated position if the forearm rotation is well maintained along with elbow stability and mobility, and the radial head is not tender. Radial head reduction requires one of the following:

• Ulnar corrective osteotomy and radial shortening (similar to an untreated Monteggia fracture-dislocation)
• Ulnar corrective osteotomy and lengthening – The distal radioulnar relationship is preserved with a wire that transfixes the 2 bones. As the ulna lengthens, the radius is pulled distally, reducing the radial head. Following reduction, additional proximal radioulnar joint reconstruction may be needed. It may also be necessary to extend the external fixation to the humerus via a hinged elbow.

Types 2 and 3 with radial head dislocation

The ulnar clubhand appearance is pronounced with these 2 types. The primary goal of treatment is to correct the alignment of the hand and forearm. If only the distal third of the ulna is absent, the ulna can be transported distally to support the carpus. If the distal two thirds of the ulna is absent, creation of a single-bone forearm is a better alternative. If forearm rotation is good, all attempts should be made to transport the ulna distally.

The radius is osteotomized at 1 or 2 places, and the alignment is corrected. The ulna is osteotomized and distracted independently or with the radius.

Type 4

The ulnar clubhand deformity and elbow stability are the main issues to consider. Both can be improved with a corrective osteotomy to realign the hand and forearm. Lengthening requires extension of the external fixation to the humerus via a hinged elbow external fixator.

Type 5

An elbow-level osteotomy is performed to correct the elbow position. A radial osteotomy, ulnar osteotomy, or both can be used to realign forearm rotation and lengthen the forearm.

Complications

Most children learn to cope functionally with their condition.

One of the common complications that is seen in the lengthening reconstruction treatment of ulnar deficiencies of the forearm is the tightening of the flexor tendons to the digits, which restricts hand function.

Dislocation of an unstable elbow is also a potential complication. This can be avoided by protecting the elbow with a hinged fixator.

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